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62 Cards in this Set
- Front
- Back
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The systematic examination of the body is
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Assessment
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What is the overall goal of a physical assessment?
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to gather objective data about the client, to evaluate the clients current physical condition, to detect early signs of developing health problems, to establish a baseline for future comparison, to evaluate the clients responses to treatment
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List the four basic physical assessment techniques?
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Inspection, Percussion, Palpation, Auscultation,
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Which assessment technique is the most commonly used?
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Inspection
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Purposeful observations; that look for specific normal & abnormal characteristics
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Inspection
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Striking or tapping a part of the body. The fingertips are used to make vibratory sounds. The quality of the sound aids in determining location of sound & aids in determining location, size & density of the underlying sructures. The client should not be uncomfortable if this is done correctly
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Percussion
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Lightly touching or applying pressure to the body with the finger tips, back of the hand or the palm. It provides information on the size shape, consistancy & mobility of masses
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Palpation
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Listening to the body sounds...heart, abdomen, lungs. uses a stethescope. Environmental noise can affect the results
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Auscultation
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What equipment is needed to preform a assessment?
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gloves, client gown, scale, thermometer, tongue blade, sphygmomanometer, cloth or paper drapes, stethescope, pen light, assessment form & pen
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List two types of physical assessments
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head to toe
body system approach |
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When using this type of assessment you gather data starting at the head & continuing to the feet
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Head to toe
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This type of assessment collects data according to the functional systems of the body
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Body Systems approach
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Which approach of assessment is most commonly used?
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Often a combination of both methods is used
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This determines the clients cognitive function provides info on memory, attention, concentration
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Mental status
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What instrument is used to examine the eyes
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opthalmoscope
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this test is used to assess how a client see near & far
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visual aquity test
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Snellen Chart & Jaeger charts are used to assess the _____
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eyes
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What is considered normal vision
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20/20
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this assessment can be especially helpful if a client has head trauma, it checks to see if both eyes do the same thing
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consensual response
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The eyes ability to constrict when looking at objects that are near & dialate when looking at items that are far
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accomodation
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PERRLA means
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pupils equally round, reactive to light & accommodation
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eye movements controlled by several pairs of eye muscles helps patient control focus & tracking movement
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extraoccular movements
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What instrument is used to exam the ears
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otoscope
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how do you straighten a childs ear?
an adults ear? |
child down & back
adult up & back |
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what is another name for earwax?
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cerumen
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this auditory exam measures the ability to hear sound frequency
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audiometry
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the septum is located _____on the nose
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midline
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What do normal mucous membranes look like?
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pink, moist & free of drainage
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How should the tongue protrude from the mouth?
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midline
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Skin should be
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smooth & unbroken
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What color is normal mucous membranes
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pink
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pallor
describe & tell causes |
pale regardless of race; causes anemia & blood loss
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erythema
describe & causes |
red
sperficial burns, local inflammation, carbon monoxide poisoning |
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Flushed
describe & causes |
Pink
fever, hypertension |
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Ecchymosis
describe & causes |
Purple
trauma to soft tissue |
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Cyanosis
describe & causes |
Blue
low tissue oxygenation |
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Jaundice
describe & causes |
Yellow
liver & kidney disease, destruction of red blood cells |
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Tan
describe & causes |
Brown
Ethnic variations, sun exposure, pregnancy, Addison's disease |
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Macule
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flat round, colored nonpalpable area ex freckles
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Papule
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elevated & palpable
ex wart |
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Vesicle
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elevated round filled with serum
Blister |
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Wheal
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elevated, irregular border, no free fluid ex hives
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Pustule
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elevated raised border, filled with pus ex boil
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Nodule
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Elevated, solid mass, deeper and firmer than a papule ex enlarged lymph node
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Cyst
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encapsulated round fluid filled or solid mass beneath the skin
ex tissue growth |
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The resiliance of the skin; elasticity
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Turgor
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Increased curve of the thoracic area
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kyphosis
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The Natural lumbar curve of the back is exagerated
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Lordosis
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pronounced lateral curvature of the spine
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scoliosis
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Lung sounds ar auscultated in the _______, ________, ______
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front (10) back (10) side (4)
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adventitious sounds are
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abnormal lung sounds ex crackles, gurgles, wheezes, rubs,
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Where should you check muscle strength?
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all four extremities
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A normal capillary refill is
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<3 seconds
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excessive fluid within the tissue is
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edema
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the amount of time it takes to blood flow to resume flowing in the base of the nail bed
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capillary refill
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intermittent high pitched popping sounds heard in distant areas of the lungs
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crackles or rales
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low pitched continuous bubbling sound heard in the larger airways
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Gurgle on Rhonchi
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Wavelike muscular contractions of the small & large intestines that can be auscultated
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bowel sounds
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bowel sounds are more frequent when?
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after eating
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How long must you listen for blowel sounds before you can say they are absent
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5 minutes
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this measurment is taken at the largest part of the abdomen
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abdominal girth
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when is the optimal time to preform a breast exam?
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monthly about one week after your menstrual period
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