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151 Cards in this Set
- Front
- Back
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Purposes of physical assessment |
Gather baseline data
compare data with history evaluate patient's changing health status evaluate outcomes of care |
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When to perform physical assessment
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Annually in office setting
At least every 8 hours in acute care As needed for change in health status Before and after treatments/proceedures |
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Considerations / prep before physical assessment
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All appropriate tools and supplies
maintain standard precautions ensure patient privacy and comfort limit interrruptions ensure adequate lighting discuss procedure with patient collect/review patient history |
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Consists of -
Biographical and demographic info HPI (History of present illness) or Chief Complaint Health History Surgical History Family History Social History Health care maintenance cultural assessment |
Patient history
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5 skills of physical assessment
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inspection, olfaction, auscultation, palpation, percussion
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Notice these key aspects of general appearance and behavior
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age, gender, race, signs of distress, body type, posture and gait, body movements, hygiene, grooming, dress, odors, affect, mood, speech
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Physical assessment includes measurement of -
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BP, pulse, respirations, temperature, O2 saturation, pain, height, weight, BMI
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5 key aspects of pain
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Onset and duration
Location Intensity Quality - i.e. throbbing, aching, sharp, burning Pattern - factors that alleviate or exacerbate Ouch, Life Is Quite Painful! (mnemonic) |
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Important history for neurological assessment
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Use of medications/drugs including analgesics, alcohol, sedatives, hypnotics, antipsychotics, antidepressants, stimulants, recreational drugs
Symptoms relating to neurological imparement - headache, tremors, dizziness, vertigo, numbness, tingling, visual changes, changes in any of the 5 senses, weakeness, pain, changes in speech, behavioral changes History of - seizures, paralysis, emotional stress, spinal cord injury, depression, anxiety, neurologic disease, congenital anomalies |
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Neurological portion of physical assessment includes -
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LOC - Level of consciousness (if low, use Glasgow Coma Scale)
Behavior, cognition, orientation Speech Cranial Nerves Pupillary response - PERRLA Motor/sensory function |
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Glasgow Coma Scale
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7 or less = coma
Rated in 3 areas: Eye opening (1-4 points) Verbal response (1-5 points) Motor Response (1-6 points) |
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PERRLA
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Pupils Even, Round (1-7 mm), Reactive to Light, and Accomodating (constricts close, dilates with distance)
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Motor/Sensory portion of assessment
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Moves all extremeties (document difficulty, weakness, numbness, tingling, etc) through normal ROM.
Balance Gait Strength of extremeties x4 - hand grasp, dorsiflection, plantar flexion of feet, leg abduction and adduction. Document as strong/weak, equal/unequal Sensation to superficial touch (absent/present) |
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Palpation portion of cardiovascular assessment includes - (5)
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Carotid, brachial, pedal pulses
PMI location Palpate temperature of extremeties Capillary refill Peripheral edema |
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Inspection portion of cardiovascular assessment (3)
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Inspect neck bilaterally (note Jugular venous distention -JVD)
Inspect nail beds for clubbing Inspect extremeties for color, hair distribution, venous pattern (varicosities), scars, pigmentation, ulcers or edema |
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Auscultation portion of cardiovascular assessment -
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Apical pulse
S1 first heart sound (lub) is closing of AV valves (mitral/tricuspid) S2 second heart sound (dub) is closing of semilunar valves (aortic/pulmonic) - listen for extra sounds S3, S4 Regular or Irregular rate Auscultate pulse rate for 1 minute with diapragm first then bell |
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Patient positioning for auscultation of cardiovascular system -
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Sitting, Supine, Left lateral
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Abnormal Heart Sounds - gallop
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Extra sound(s) S3, S4
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Abnormal Heart Sounds - click
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mitral valve prolapse
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Abnormal Heart Sounds - rubbing
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Pericardial friction rub - may sound like squeaking or rubbing leather together caused by inflamation of pericardium
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Abnormal Heart Sounds - squish/swoosh noise
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Heart murmur - caused by incomplete valve closure (i.e. lub-swoosh-dub)
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Pain symptoms related to cardiovascular system -
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Chest Pain
Signs of occlusion - pain, pallor, lack of pulse, paralysis Signs of phlebitis - localized tenderness, swelling, warmth, edema in one calf Homan's sign - dorsiflexion of foot causes tenderness in calf |
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Important history related to lung assessment
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Allergies
Tobacco/marijuana use Any symptoms/history of impared lung function (persistent cough, voice change, SOB, orthopnea, activity intolerance, pneumonia, bronchitis, wt loss, fatigue, night sweats, fever) Work environment Risk for TB - HIV, low income, resident/employee of institutional facility Family history of cancer, allergies, TB Vaccination status for pneumonia, flu, TB |
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Inspection portion of lung assessment
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Respiration rate and rhythm (regular or irregular)
Depth/Volume (deep, shallow, diaphragmatic, accessory) Quality (labored, dyspnea, orthopnea) Symmetry |
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Auscultation portion of lung assessment
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Listen to at least 8 locations anteriorly, 12 posteriorly plus rt middle lobe (5th-6th intercostal space on rt midaxillary line).
Indetify qualities of breath sounds |
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Vesicular breath sounds
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Normal, soft, breezy, low-pitched sounds. Created by air moving through small airways. Best heard over periphery. Inspiratory 3x longer than expiratory.
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Bronchovesicular breath sounds
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Normal, blowing sounds, medium pitch & intensity. Air blowing through large airways. Best heard posteriorly through large airways between scapulae and anteriorly to left and rt of sternum at 1st and 2nd intercostal spaces. Inspiration equal to expiration.
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Bronchial breath sounds
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loud and high-pitched with hollow quality created by air moving through trachea close to chest wall. Heard over trachea. Expiration longer.
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Wheeze
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high-pitched musical squealing heard most predominantly on expiration
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Pleural Friction Rub
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Course low-pitched sound resembling 2 pcs of leather rubbing together
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Stridor
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Harsh high-pitched sound heard on inspiration due to severe narrowing
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Fine Crackles (rales)
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Discontinuous high-pitched popping sounds heard during inspiration
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Course Crackles
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Loud, low-pitched bubbling and gurgling sounds. May decrease with coughing but will return shortly. Heard on early inspiration and expiration.
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Rhonchi
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Low-pitched musical snoring heard throughout cycle but most prominent on expiration. May clear with coughing. Usually caused by secretions in bronchial airways
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Important history related to abdominal assessment
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Use of anti-inflamatory meds, antibiotics, ETOH, laxatives
Assess changes/issues related to digestion Family history of IBS, cancer, kidney disease, alchoholism, hypertension, heart disease Patient history of abdominal issues, surgery, etc. |
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Inspection portion of abdominal assessment
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Observe for evidence of pain (splinting, guarding, etc.)
Inspect skin for color, scars, venous patterns, lesions, striae (stretch marks), bruising, ostomies, tubes drains. Inspect contour for symmetry, surface motion, masses, bulging, distention Note position of umbillicus (flat, concave - should not have color difference or discharge) Note movement and pulsations |
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Auscultation portion of abdominal assessment
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Bowel sounds - audible passage of air and fluid that peristalsis creates.
Listen about 30 seconds per quadrand - typically about 5-35 sounds per minute Listen 1 full minute before determining absence Best time to auscultate is between meals Absent bowel sounds indicate lack of peristalsis |
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Bowel sounds may be described as -
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Normal, audible, absent, hyperactive, hypoactive
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Abdominal vascular sounds are called _____ and are caused by _________
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bruits, caused by narrowing of major blood vessels which disrupts flow
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Location of 3 primary abdominal vascular sounds
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Aorta - midline through abdomen
Renal Arteries - Upper quadrants anteriorly Femoral Arteries - Lower quadrants |
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When examining the abdomen, remember to use skills in what order?
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Always auscultate before palpating because palpation may significantly alter bowel sounds.
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Ischemia
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temporary deficiency of blood flow to an organ or tissue
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Necrosis
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death of cells, tissues and organs
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Erythemia
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Reddening of skin. Common but non-specific sign of injury, irradiation, inflamation
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Excoriation
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abrasion of skin or other organs
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Atrophy
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decrease in size of an organ or tissue
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Keloid
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exuberant scar that forms at site of injury or incision that spreads beyond initial boundaries of lesion
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Macule
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flat, non-palpable change in sckin color smaller than 1mm (freckle, petichia)
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Papule
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Solid elevation in skin. Palpable, circumscribed, smaller than 1cm
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Nodule
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Elevated solid mass, deeper and firmer than a papule. 1cm-2cm (Wart)
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Tumor
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Solid mass that extends deep through subcutaneous tissue. Larger than 1-2cm.
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Wheal
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Irregularly shaped elevated area or superficial localized edema. Varies in size (mosquito bite, hive)
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Vesicle
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Circumscribed elevation of skin filled with serous fluid smaller than 1cm (Herpes simplex, chicken pox)
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Bulla
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A large blister or skin vesicle filled with fluid (burn, friction blister)
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Pustule
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A small elevated skin lesion filled with white blood cells and sometiems bacteria or the products of broken down cells (as seen in acne vulgaris)
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Ulcer
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Deep loss of skin surface that extends to the dermis and frequently bleeds and scars. Varies in size (eg. Venous stasis ulcer)
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Palpate skin for what 3 characteristics?
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Temperature
Turgor Edema |
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Acromegaly
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a disorder caused by excessive secretion of growth hormone
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Adventitiuos sounds
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"extra" sounds that are abnormal
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Alopecia
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hair loss
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Aneurysm
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localized, blood-filled balloon-like bulge in the wall of a blood vessel.
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Aphasia
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Impairment of language ability. This class of language disorder ranges from having difficulty remembering words to being completely unable to speak, read, or write.
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Arcus senilis
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white or gray, opaque ring in the corneal margin (peripheral corneal opacity), or white ring around the iris. It is present at birth, but then fades; however, it is quite commonly present in the elderly. It can also appear earlier in life as a result of hypercholesterolaemia.
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Atherosclerosis
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(also known as ASVD) is a condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol.
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Atrophied
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reduced in size
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Basal cell carcinoma
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a cancerous skin lesion that is most common in sun-exposed areas of the body and frequently occurs in a background of sun-damaged skin. Rarely spreads.
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borborygmi
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hyperactive bowel sounds. Also known as stomach growling, rumbling, gurgling, grumbling or wambling, is the rumbling sound produced by the contraction of muscles in the stomach and intestines
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bronchophony
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Normally, vocal sounds heard through the chest wall are muffled. If fluid is compressing the lungs, the sound is transmitted more clearly. This effect is called bronchophony
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bruit
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When the lumen of a blood vessel is narrowed, it creates turbulent flow that produces a blowing or swishing noise. This sound is typically best auscultated by placing the bell of the stethoscope over the carorid artery. Thrill is a palpable bruit
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capillary refill
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is the rate at which blood refills empty capillaries. It can be measured by holding a hand higher than heart-level (prevents venous reflux), pressing the soft pad of a finger or toe until it turns white, and taking note of the time needed for the color to return once pressure is released. Normal refill time is less than 2 seconds.
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cerumen
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ear wax
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chancre
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is a painless ulceration (sore) formed during the primary stage of syphilis.
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cherry angiomas
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Ruby red papules (a normal age-related skin change)
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cholecystitis
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Cholecystitis is inflammation of the gall bladder.
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clubbing
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change in angle between the nail and nail base. Nail bed softening with nail flattening and often includes enlargement of the finger tips. Indicates chronic oxygenation problems.
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conjunctivitis
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infection of the conjunctiva of the eye
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cyanosis
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a bluish tint caused by lack of O2. Best observed in lips, nail beds, palpebral conjunctivae and palms. Could be due to cold-induced vascular constriction, anemia, airway defficiencies, or cardiovascular deficiencies.
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dermatitis
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can refer to many skin conditions with various symptoms including itching, dryness, and/or rash. Could be due to contact with allergen, dry environment, buildup of blood in lower legs due to immobility or other factors.
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distention
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swelling
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dysrhythmia
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failure of the heart to beat at regular successive intervals
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ectropion
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eyelid margins that turn out
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eczema
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skin condition characterized by dry, flaky areas
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edema
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Areas of the skin become swollen from a buildup of fluid in the interstitial spaces of the tissues. Direct trauma and impairment of venous return are two common causes of edema.
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entropion
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eyelid margins that turn in (eyelashes may irritate eye)
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erythema
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red discoloration of the skin (i.e. sunburn, inflammation, fever)
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exopthalmos
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bulging eyes
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exostosis
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is the formation of new bone on the surface of a bone. Exostoses can cause chronic pain ranging from mild to debilitatingly severe, depending on where they are located and what shape they are.
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goniometer
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a tool for measuring range of motion
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Hemorrhoids
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varicosities of the anal canal
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hernia
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protrusion of abdominal organs through the muscle wall
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hirsutism
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a condition which causes females to develop more male-like hair growth. Vellus hair of upper lips, chin, cheeks and body becomes thicker and darker.
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hydrocephalus
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a buildup of cerebrospinal fluid in the ventricles
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hypertonicity
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when describing muscle, it means increased tone, a tight muscle that will provide considerable resistance to sudden passive movement. Continued movement of the joint will eventually cause the muscle to relax
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indurated
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hardened
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integument
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skin, hair, scalp, and nails
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jaundice
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yelow-orange discoloration typically due to poor liver function. Best observed in client's sclera.
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kyphosis
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also called roundback or Kelso's hunchback, is a condition of over-curvature of the thoracic vertebrae (upper back).
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leukoplakia
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thick white patches on the mucosa that are often precancerous lesions. More common in heavy smokers and alcoholics.
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lordosis
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an abnormal inward curvature of a portion of the lumbar and cervical vertebral column.
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melanoma
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an aggressive form of skin cancer
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metastasize
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the spread of a disease from one organ or part to another non-adjacent organ or part.
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murmurs
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sustained swishing or blowing sounds heart when auscultating the heart. Due to increased flow through a normal valve, a stenoic valve, or through a leaky valve
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nystagmus
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an involuntary rhythmical oscillation of the eyes
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occlusion
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blockage
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orthopnea
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shortness of breath (dyspnea) that occurs when lying flat.
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ototoxicity
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injury to the auditory nerve. May be a result of high maintenance doses of antibiotics (eg aminoglycosides)
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palpation
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involves using the hands to touch body parts to make sensitive assessments. Use different parts of the hand for different types of palpation. For example, use the dorsal side of hand to assess temperature and fingertips for detecting masses. Light intermittent pressure is best because heavy prolonged pressure reduces sensitivity of the fingers. Always assess painful areas last.
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pancreatitis
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is inflammation of the pancreas.
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paralytic ileus
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is a disruption of the normal propulsive ability of the gastrointestinal tract. Often a bowel obstruction
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peritonitis
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inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera.
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petechiae
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pinpoint-sized red or purple spots caused by small hemorrhages in the skin layers. Could indicate serious blood-clotting disorder, drug reactions, or liver disease.
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phlebitis
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an inflammation of a vein, usually in the legs.
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PMI
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Point of maximal impulse, where heart beat is heard most clearly due to close proximity of apex of heart to chest wall. 5th intercostal space on left midclavicular line
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polyps
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tumor-like growths
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ptosis
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abnormal drooping of the eyelid over the pupil
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Scoliosis
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lateral spinal curvature
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senile keratosis
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a thickening of the skin commonly seen in elderly clients - a normal age-related skin change
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squamous cell carcinoma
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a cancerous skin lesion that is more serious than basal cell carcinoma. It develops on the outer layers of sun-exposed skin. These cells may travel to lymph nodes and throughout the body.
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stenosis
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narrowing
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striae
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stretch marks
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syncope
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loss of consciousness
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tactile fremitus
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Also called vocal fremius. Vibrations of sound waves (generated when the patient speaks) that can be palpated externally. The accumulation of mucus, collapse of lung tissue, or presence fo lung lesions will block vibrations from reaching the chest wall.
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thrill
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a continuous palpable sensation like the purring of a cat (may be related to heart murmur or palpable bruit).
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turgor
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the skin's elasticity - used in assesing hydration or edema
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varicosities
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swollen tortuous veins that are common in older adults and rarely cause problems
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ventricular gallop
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S3, occurs just after S2 and creates a heart rhythm with a Ken-tuck-y sound to it. Due to a premature rush of blood into a ventricle that is stiff or dilated as a result of heart failure and hypertension
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vocal fremitus
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also called tactile fremitus. Vibrations of sound waves (generated when the patient speaks) that can be palpated externally. The accumulation of mucus, collapse of lung tissue, or presence fo lung lesions will block vibrations from reaching the chest wall.
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whispered pectoriloquy
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Certain lung abnormalities cause the whispered voice to become clear and distinct when auscultated through the chest wall. This effect is called whispered pectoriloquy
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Important characteristics of sounds -
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Frequency (pitch)
Loudness Quality (i.e. blowing, gurgling) Duration |
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Odor of alcohol on breath may indicate
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indicates alcohol consumption or diabetes
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odor of ammonia in urine may indicate
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UTI, renal failure
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odor of feces in mouth or vomitus may indicate
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bowel obstruction
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foul-smelling stools in infant may indicate
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malabsorption syndrome
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Sweet, fruity ketones on breath may indicate
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diabetic acidosis
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stale urine smell on skin may indicate
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uremic acidosis
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Musty odor on casted body part may indicate
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infection inside cast
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Fetid, sweet odor on tracheostomy or mucus secretions may indicate
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infection of bronchial tree
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To assess for substance abuse, use
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CAGE questions - tried to CUT DOWN? Others ANNOYED? Ever feel GUILTY? Use substance as EYE-OPENER (to feel normal)?
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A weight gain of ____ lbs in one day indicates fluid retention problems. A loss of more than ___ % in one month or ___% over 6 months may indicate a serious problem
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gain of 5lbs in one day
loss of 5% in 1 month or 10% over 6 months is rapid weight loss. |
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Drug abuse associated with diaphoresis
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sedative hypnotic (including alcohol)
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drug abuse associated with spider angiomas
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alcohol, stimulants
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drug abuse associated with burns (especially of fingers)
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alcohol
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drug abuse associated with contusions, abrasions, cuts, scars
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alcohol, other sedative hypnotics
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drug abuse associated with "homemade" tattoos
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Cocaine, IV opiods (to mask injection sites)
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Drug abuse associated with increased vasculatiry of face
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alcohol
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drug abuse associated with red, dry skin
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phencyclidine (PCP)
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Splinter hemorrages (red or brown linear streaks in nail bed) may indicate
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trauma, cirrhosis, diabetes mellitus, or hypertension
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Dilated pupils may indicate
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glaucoma, trauma, neurological disorders, eye medications (eg atropine), or withdrawal from opioids
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pinpoint pupils are a common sign of
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Opioid intoxication
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A heart murmur heard between S1 and S2 is called a
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systolic murmur
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Pitting edema scale
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1+ Mild pitting, less than 2mm indentation, no perceptable swelling of the extremety
2+ Moderate pitting, 2-4mm indentation subsides rapidly 3+ Deep pitting, 4-6mm indentation remains for a short time, extremety looks swollen 4+ Very deep pitting, 6-8mm indentation lasts a long time, extremety is very swollen |
