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445 Cards in this Set

  • Front
  • Back
The basis for the nursing process is the _____.
health assessment
A health assessment provides _____ for which you can compare subsequent assessments.
baseline data
The health assessment gives information about the client's ____ and _____.
health status
health problems they have
Components of the health assessment include:
health history and the physical examination or assessment
Health history provides ____ data.
subjective
____ history focuses the physical assessment.
Health
The physical assessment provides ______ data.
objective
The ____ data can validate or refute a client's complaint.
objective
_____ data are the signs and ____ data are the symptoms.
Objective
Subjective
Guidelines for performing a physical assessment include:
-having a sequence (head to toe/ system approach)
-having instruments/equipment that are working, organized, and warmed
The instrument used to examine the eyes is the _____.
opthalmoscope
The instrument used to examine the ears is the ______.
otoscope
The instrument used to examine distance vision is the _______.
snellen chart
The instrument used to examine the nares is the ______.
nasal speculum
The instrument used to examine the cervix and vagina is the _____.
vaginal speculum
The instrument used to determine the difference between a conductive or sensory neural hearing loss is the _____.
tuning fork
The instrument used to examine the deep tendon reflexes is the ______.
percussion/reflex hammer
When positioning a patient for physical assessment the following considerations should be made:
-age of client
-health status of client
-mobility and physical condition of client
-privacy and comfort
The ____ position has the client on his/her back.
supine
The ____ position has the client on his/her back with the knees bent and feet on the table.
dorsal recumbent
The ____ position has the client in a side-lying position.
sims'
In the ____ position, the client is on his/her abdomen.
prone
In the ____ position the client lies on her back with legs in stirrups.
lithotomy
The _____ and _____ positions are uncomfortable and embarrassing therefore the client should be in the position for as little time as possible.
lithotomy and knee-chest
When preparing the environment for an assessment, the following should be done...
-provide privacy
-prepare the patient by telling them what you are going to do
-limit noise
-provide comfort to patient (voiding, temperature, pain)
-lighting
-have needed equipment
-work around meals, treatments and visiting hours
What are the 4 assessment techniques?
inspection
palpation
auscultation
palpation
_____ is deliberate, purposeful observation.
Inspection
When performing inspection it is important to assess for:
-size, shape, color
-position
-symmetry
-deviations from normal
During inspection the nurse will use the senses of
sight, smell and hearing.
_____ is assessment through touch.
Palpation
When performing palpation it is important to assess for:
-temperature, texture
-moisture, turgor
-pain, tenderness
-vibration, pulsation
-edema, distention
-masses
_____ is the presence of fluid in the interstitial spaces.
Edema
______ means swollen.
Distention
When palpating a mass you should note:
-size, shape, location
-consistency/surface
-mobility
-tenderness
Use the _____ surface of the hand to palpate for vibrations.
palmar
Use the ____ surface of the hand to palpate lymph nodes, the breasts, and pulse.
finger pads
Use the _____ surface of the hand to palpate temperature.
dorsum
____ palpation is used to assess for pain or tenderness.
Light
____ palpation is used to assess underlying organs and masses.
Deep
____ is the striking of one object against another producing vibrations which cause a sound.
Percussion
Percussion is helpful in assessing the...
location, size, shape, and density of tissues
The five percussion tones are:
flatness
dullness
resonance
hyperresonance
tympany
____ is the percussion tone heard over dense tissue like muscle or bone.
Flatness
____ is the percussion tone heard over fluid filled tissue.
Dullness
____ is the percussion tone heard over air filled tissue.
Resonance
_____ is the percussion tone heard in overinflated air filled lungs.
Hyperresonance
_____ is the percussion tone heard over enclosed air containing structures.
Tympany
Flatness may be heard when percussing _____.
bone or muscle
Dullness may be heard when percussing _____.
liver and spleen
Resonance may be heard when percussing _____.
normal lung
Hyperresonance may be heard when percussing _____.
an overinflated air filled lung
Tympany may be heard when percussing ______.
abdomen
___ is described as a soft, high-pitch, short dull sound.
Flatness
____ is described as a soft to moderately loud; medium pitch; and "thudding."
Dullness
____ is described as a moderated to loud sound; low pitch; hollow.
Resonance
_____ is described as a loud, low-pitch, "booming" sound.
Hyperresonance
____ is described as a loud, high-pitch, "drum-like" and "musical."
Tympany
Percussion is useful because it can tell _____ and indicate ____.
size/shape of organ
presence or growth/tumor
_____ is listening with a stethoscope to sounds produced within the body.
Auscultation
When auscultation is used as an assessment technique, the following characteristics are noted:
pitch
amplitude
quality
duration
____ of an auscultated sound is the frequency of vibrations per second.
Pitch
____ of an auscultated sound is loudness.
Amplitude
____ of an auscultated sound is a subjective description.
Quality
_____ of an auscultated sound tells whether the sound is short/long.
Duration
You should not auscultate over ____.
bone
A _____ should occur at first interaction with the client.
general survey
____ means there is no outward expression of internal emotion.
Flat affect
1 year olds should be weighed _____.
totally nude
When measuring the height of 2 year olds they should be in the ____ position with _____.
recumbent
extremities stretched
Measure the head circumference of children up to age ____.
2
A general survey includes:
-sex, age, race
-general appearance and behavior
-vital signs, height, and weight
-
A nursing history should include:
-current symptoms
-past history
-family history
-lifestyle and health practice (diet, smoking, alcohol, drugs)
-Current symptoms (OLDCARTSS)
OLDCARTSS stands for what when discussing current symptoms?
Onset
Location
Duration
Characteristics
Associated symptoms
Relieving/aggravating factors
Treatment
Sequence
Summarize
The primary function of the integumentary system is ____.
protection
also regulated body temperature
When taking the health history of the skin document...
-rashes, lesions, itching, skin diseases
-bruising, bleeding,
-hair loss or changes
-woulds, bruises, abrasions, burns
-change in color, size, shape of mole
-family history
____ is redness of the skin. It can be caused by sunburn, fever, inflammation, or allergic reactions.
Erythema
____ is blueness of the skin. It can be caused by cardiac or respiratory disease.
Cyanosis
Cyanosis is the presence of _____.
deoxygenated hemoglobin.
In dark skinned people cyanosis can be seen by looking at...
the conjunctiva of the eye or oral mucous membrane.
In dark skinned people jaundice can be assessed for by looking at the...
sclera of the eye, nail beds, palms/soles
_____ appears as yellowing of the skin.
Jaundice
____ is paleness of the skin.
Pallor
To assess for pallor one should look at...
oral mucous membranes, nail beds, palms/soles
_____ is seen as patches of hypopigmented skin. It may be an autoimmune response.
Vitiligo
During inspection of the integument you should assess:
-vascularity
-lesions
-wounds
-rashes
-nails
-hair and scalp
When assessing ____ you look for ecchymosis, hematoma, and petechiae.
vascularity
When assessing lesions, the different types are...
macule
papule
pustule
vesicle
When assessing nails look for
brittleness, thickness and clubbing
When assessing the hair and scalp look at
color, texture, and distribution
alopecia
hirsutism
_____ is bleeding into the subcutaneous tissue; a bruise.
Ecchymosis
_____ is accumulation of blood in tissue or an organ (swelling).
Hematoma
_____ are pinpoint red hemorrhages.
Petechiae
A ____ is a flat unelevated change in color; freckles, measles rash, port wine stain.
macule
A ____ is a solid elevation of skin that may or may not have a change in color; mole or wart.
papule
A ____ is a vesicle filled with puss; acne vulgaris.
pustule
A _____ is a round or oval thin translucent mass filled with serous fluid; chicken pox rash, blood blister, poison ivy, burn blisters.
vesicle
Nails should be _____ and ____.
convex and smooth
____ is the thickening and flattening of distal phalanges and comes from long term inadequate oxygenation.
Clubbing
____ is loss of hair.
Alopecia
____ is the growth of coarse hair on the face and trunk. It can be caused by ovarian dysfunction.
Hirsutism
When assessing the integument through palpation you should assess:
temperature, moisture
turgor
edema
texture
____ is excessive sweating.
Diaphoresis
When palpating the skin for temperature, and moisture you should make note of whether the client shows signs of ____ or _____.
diaphoresis or dehydration
____ is elasticity.
Turgor
Decreased turgor can be seen because the skin will show _____, evidence of dehydration.
tenting
_____ individuals have less skin elasticity.
Elderly
When assessing for edema it can be rated as ____.
0 thru 4+
A child in the first 28 days of life is referred to as _____.
neonate/newborn
A child between 28 days and 1 year old is called a _____.
infant
In a newborn, skin turgor should be assessed...
on the abdomen
A newborn has skin that is smooth and thin meaning that the blood vessels are close to the surface which predisposes them to
heat loss and moisture loss.
_____ is fine hair over the body of a newborn.
Lanugo
_____ is the yellowish-whitish cheese substance that is in the folds/creases of a newborns skin. It is a mixture of epithelial cells and sebum that moisturizes.
Vernix Caseosa
_____ is baby acne.
Milia
______ looks like a dark bruise-patch over the sacral area.
Mongolian Spot
____ jaundice is a normal variation.
Physiologic
In adolescents, _____ indicates the onset of puberty.
axillary and pubic hair development
Several variations in the skin of elderly adults include:
-wrinkles, dryness
-lentigines ("age spots")
-telangiectasias (spider veins)
-hair changes
-nail changes
Wrinkles and dryness occur in elderly adults because of decreased...
-elasitcity
-sweat and sebaceous glands
-subcutaneous fat
____ is nose bleeds.
Epistaxis
Assessment of the head and neck include:
inspection, palpation, and percussion
When assessing the skull you should assess for
size, shape, symmetry and any other abnormal findings.
____ means normal in size, shape, and symmetry.
Normocephalic
____ is a small head.
Microcephaly
____ is a large head.
Hydrocephaly
When assessing the face, assess for
color, symmetry, hair, and other abnormal findings such as edema, tics, tremors, and nodules/masses.
____ are abnormal involuntary facial movements.
Tics
____ are involuntary movements like shaking.
Tremors
When assessing the eyes you should look for
-position, alignment, symmetry, color
-pupils (PERRLA)
-visual acuity
-extra-ocular movements
-visual fields
-other abnormal findings
_____ is the constriction of your pupil that occurs when the focus of vision moves from a far to a near object.
Accommodation
In the pupils response to light you should expect to see
constriction of both pupils.
In ____ response to light the pupil of the eye you shine light in constricts.
direct
In ____ response the light the pupils of both eyes constrict.
conscentual
____ happens when you bring something close to the eyes and the eyes move in.
Convergence
____ is abnormal dilation of the pupils.
Mydriasis
____ is abnormal constriction of the pupils.
Miosis
_____ is unequal pupils.
Anisocoria
Abnormal findings of the eyes include:
-mydriasis
-miosis
-anisocoria
-decreased/absent response
____ is the assessment of distance vision.
Visual acuity
____ is nearsightedness.
Myopia
_____ is farsightedness.
Hyperopia
____ is abnormal curvature of the cornea that prevents light rays from focusing on the retina.
Astigmatism
____ is a droopy eyelid.
Ptosis
____ is called a lazy eye.
Strabismus
____ is involuntary eye movement.
Nystagmus
Ear assessment should consider:
external ear
ear canal
tympanic membrane
and other abnormal findings
When assessing the external ear assess
-shape, size
-symmetry
When assessing the ear canal it should be
smooth and pink
When assessing the tympanic membrane it should be
translucent and gray
clearly defined landmarks
Abnormal findings of the ear include:
drainage, pain and redness
There are 3 types of hearing loss:
conductive
sensory neural
mixed
In ____ hearing loss there is a problem with the transmission of sound waves through the outer and middle ear.
conductive
In ____ hearing loss the damage is in the inner ear.
sensory neural
Two tests of hearing loss that are done with a tuning form to differentiate between conductive and sensory neural hearing loss are...
Webers Test and Rinne's test
The hearing test that uses headphones allowing the person to hear beeps at varying frequencies is called an _____.
audiometry
Assessment of the mouth includes
lips, tongue, gums
hard and soft palates
teeth
abnormal findings
Assessment of the pharynx should include
tonsils and other abnormal findings such as exudate, swelling, bleeding and discharge
When assessing the nose check
patency
nasal septum
and other abnormal findings such as polyps
____ are smooth, pale gray growths that are associated with chronic allergies.
Polyps
When assessing the sinuses check for
pain and edema.
In the mouth the mucous membranes should be
moist and pink
Assess the palate of an infant by palpating for _____.
cleft palate
A ____ mouth odor signals possible diabetes.
acetone
A ____ mouth odor signals possible uremia.
ammonia
A ____ mouth odor signals possible liver disease.
musty
The sinuses that can be percussed are the
frontal and maxillary
Assessment of the neck include:
inspection and palpation
When assessing the neck you should check
-ROM
-trachea
-thyroid
-lymph nodes
-venous distension
The thyroid is not normally ___.
palpable
Venous distension in the ___ position is never normal and may indicate CHF or venous overload.
upright
____ are enlarged lymph nodes.
Lymphadenopathy
Enlarged lymph nodes are caused by
infection
autoimmune diseases
cancer
The anterior fontanel of infants should close by
18-24 months
The posterior fontanel of infants is smaller and should close by
8 weeks of age.
Inspect babies hard and soft palates for ____.
clefts
____ is when babies appear to have strabismus because they have an epicanthal fold that covers the inner corner of sclera of eye.
Pseudostrabismus
All deciduous teeth should erupt in children by age
2 1/2 years
Visual acuity should be 20/20 by ___ years of age.
6
____ is generalized loss of hearing acuity that occurs with age- especially high frequency sounds.
Presbycusis
____ is impaired near vision in elderly adults.
Presbyopia
____ is an inversion of the lower lid.
Entropion
____ is an eversion of the lower lid.
Ectropion
Lymph glands in elderly adults are _____.
smaller
Neck veins in elderly adults are _____ because there is loss of subcutaneous fat.
more prominent
The ____ is elderly adults is more nodular.
thyroid gland
_____ are yellowing of the lens of the eye.
Cataracts
____ is an abnormal fluid balance causing increased intraocular pressure.
Glaucoma
____ is the leading cause of blindness in people over age 40.
Glaucoma
The functions of the lungs are
gas exchange and promote acid base balance.
The right lung has ____ lobes.
3
The left lung has ____ lobes.
2
The ____ lung sits higher because of the placement of the liver.
right
The ____ lung is more narrow because of the placement of the heart.
left
Gas exchange takes place in the _____.
alveoli
The _____ pleura lines the chest cavity.
parietal
The _____ pleura covers the lungs.
visceral
The primary muscles used in breathing are the
diaphragm and intercostals.
_____ means you need to be upright to breath.
Orthopnea
Cardiac pain is different than chest pain because cardiac pain...
can radiate or move to other areas.
Important information to get regarding the history of the thorax and lungs includes:
-trauma or surgery
-difficulty breathing
-use of pillows to breathe when sleeping
-chest pain with deep breathing
-persistent cough
-allergies
-environmental exposure, smoking
-lung disease
-respiratory infections
-family history
Equipment needed for assessment of the lungs and thorax include:
hands, stethoscope and pulse oximeter
The best position for assessing the lungs and thorax is
sitting upright because it allows optimum expansion of the lungs.
When we assess the lungs we are assessing ____ which is the person's ability to take in oxygen and blow off carbon dioxide.
aeration status
Assessment techniques used with the lungs and thorax include:
inspection
palpation
percussion
auscultation
On inspection of the lungs note the
-color
-shape, symmetry
-contour
-respiratory rate
The ____ diameter should be larger than the ______ diameter.
transverse
anteroposterior
The anteroposterior diameter should be about ____ the transverse diameter.
1/2
Abnormal findings upon inspection of the lungs and thorax include:
-barrel chest
-retractions
-unequal chest expansion
-nasal flaring
-pursed lip breathing
-adventitious breath sounds
-abnormal breathing patterns
______ is the use of accessory muscles to breathe.
Retraction
During retraction the person is trying to
increase compliance and recoil of the lungs.
Retractions can be classified as
supracostal
intercostal
subcostal
____ is a way that the body tries to get more oxygen into the lungs and it occurs on inspiration.
Nasal flaring
Palpation of the lungs and thorax allows you to assess for
-temperature
-moisture
-chest expansion
-tactile fremitus
-Abnormal findings
-pain, tenderness
-masses
-unequal chest expansion
-vibratory sensations
-crepitus
_____ is a mild vibratory sensation that occurs as sound waves move thru the upper respiratory tract, lower respiratory tract and to the chest wall.
fremitus
____ is subcutaneous air in the chest; it feels like a crackling in your chest.
Crepitus
Percussion allows you to assess the lungs and thorax for
-lung size and position
-presence of air, liquids, or solids
-percussion tones
The normal percussion tone in the lungs is ______.
resonance
_____ is a percussion tone of the lungs that occurs with increased air or air trapping.
Hyperresonance
____ could indicate the presence of fluid, a tumor, or another solid mass in the lungs.
Dullness
____ is listening for movement of air into and out of the respiratory tract.
Auscultation
There are ___ areas to auscultate on the anterior thorax.
7
There are ___ areas to auscultate on the posterior thorax.
10
When discussing breath sounds auscultated in the lungs it is important to note ____, ____, and _____.
duration, pitch, and intensity
Normal breath sounds include:
bronchial
bronchovesicular
vesicular
_____ breath sounds are heard anteriorly over the trachea.
Bronchial
_____ breath sounds are heard over the main stem of the bronchus (either side of sternum) or between the scapula.
Bronchovesicular
_____ breath sounds are heard over smaller airways (alveoli) and everywhere else.
Vesicular
_____ breath sounds are short on inspiration and long on expiration. They sound like air blowing thru a pipe.
Bronchial
_____ breath sounds have equal inspiration and expiration.
Bronchovesicular
_____ breath sounds are softer sounds kind of like a sigh. The inspiration is longer that the expiration.
Vesicular
Stertuous breathing, stridor, crackles, rhonchi, wheezes, pleural friction rub, and diminished or absent breath sounds are all examples of ____ breath sounds.
adventitious
____ are heard when air moves thru airways filled with fluids/secretions. It is discontinuous.
Crackles
Crackles means there is _____ in airways.
secretions/fluids
_____ occur when the airway is narrowed due to secretions, swelling, tumor, etc...
Rhonchi
Rhonchi can be heard over _____.
larger airways
____ are heard over smaller airways and are generally heard more on expiration.
Wheezes
_____ is due to inflammation of pleural linings. It is heard on inspiration and expiration.
Pleural friction rub
_____ is noisy strenuous respirations.
Stertuous breathing
____ is due to narrowing of the upper airway, particularly around the larynx and trachea.
Stridor
Stridor can be heard ____ a stethoscope.
without
_____ are anything other than normal, occur when air passes thru an airway that is narrow, filled with fluid or mucous, or the pleural linings are inflamed.
Adventitious breath sounds
The following are thorax/lung variations among children:
-more rapid respiratory rate
-nose breathers
-thorax rounded
-abdominal muscles used during respiration
The following are thorax/lung variations among elderly:
-increased AP chest diameter
-lungs less elastic, thorax more rigid
-kyphosis
-decreased ciliary action
-decreased surfactant production
____ is an increase in the dorsal spinal curve (hump back) and it can affect the ability of the lungs to expand.
Kyphosis
Decreased surfactant production in the elderly is dangerous because it leads to an increased risk for...
alveoli to collapse
____ is ventricular filling while ventricles relax.
Diastole
____ is contraction of the ventricles which causes them to empty.
Systole
During diastole the ___ valves are open and the ____ valves are closed.
a/v
SL
During systole the ___ valves are open and the ____ valves are closed.
SL
AV
The ___ of the lungs points towards the back of the body.
base
The apex touches the chest wall at the 5th intercostal space and midclavicular line. This is called the ____.
PMI
PMI stands for
point of maximum impulse
____ are when you can feel your heart beating in your chest.
Palpitations
When collecting history related to the cardiovascular system is it important to note:
-chest pain, palpitations
-dyspnea; pillows to sleep
-HTN, coronary artery disease, CHF, myocardial infarction, etc
-heart surgery
-edema, color changes, temp. of extremities
-sores on legs that don't heal
-cholesterol levels, smoking, alcohol
-diet, activity
-family history
Edema, changes in color or temperature of extremities and sores on legs that do not heal are examples of
peripheral vascular disease
Cardiovascular Assessment
Equipment-
Position-
Environment-
Assessment Techniques-
Equipment- stethoscope, hands, BP cuff
Position- upright
Environment- well-lit and quiet
Assessment Techniques- all except percussion
The 4 cardiac landmarks that are auscultated are the
aortic valve- 2nd intercostal R
pulmonary valve- 2nd inter. L
tricuspid valve- 4th inter. L
mitral valve- 5th inter. mid clav line
The ____ is the area of the chest that overlies the heart.
precordium
When inspecting the cardiovascular system note the
-epigastric area
-pulsations
-abnormal findings such as
-neck vein distention
-visible pulsations
The only place that visible pulsations are normal is the ___.
PMI
_____ are vibratory sensations int he cardiovascular system that are usually associated with murmurs.
Precordial thrills
____ are rises along the sternal border that occur with each heart beat.
Lifts or heaves
Heart sounds are caused by
closure of the heart valves.
Assess heart sounds for
-rate and rhythm
-abnormal sounds
-extra heart sounds
The first heart sound is
Lub (S1)
The second heard sound is
dub (S2)
The lub heart sound is louder in the ____ and ____ valve areas.
mitral and tricuspid
The dub heart sound is louder in the ____ and ____ valve areas.
aortic and pulmonic
Lub corresponds with ventricular ____.
systole
Dub corresponds with ventricular ____.
diastole
____ are heard when the valve is deformed and doesn't open all the way.
Ejection clicks
A ____ is due to turbulent blood flow in the heart or great vessels. It is heard over the heart and great vessels.
murmur
A ____ is turbulence to the blood flow thru the great vessels. It is heard over the carotid, epigastric, and femoral areas.
bruit
____ heart sounds are normal in children and young adults.
S3
____ heart sounds are normal in elderly adults.
S4
____ is blood supply to the extremities.
Perfusion
Capillary refill should be less than ____ seconds.
2
The peripheral vascular system includes
blood pressure, peripheral pulses, and perfusion
Abnormal findings of the peripheral vascular system that may indicate PVD are:
-pallor
-edema
-ulcers, changes in pigmentation (brownish)
-hair loss
-thickened toenails
During assessment of the peripheral vascular system you should check
capillary refill and pedal pulse.
A 1+ peripheral pulse is hard to feel, easily obliterated by slight finger pressure and described as
weak and thready.
A 0 peripheral pulse is
absent
A 2+ peripheral pulse is easily palpable and can be obliterated by strong pressure. It is considered
normal
A 4+ peripheral pulse is readily palpable, forceful and not easily obliterated. It is described as
bounding
An ____ peripheral pulse is strong on one side and not on the other.
assymetric
____ is inflammation of a vein.
Phlebitis
Homan's sign is a type of phlebitis. It is assessed by
dorsiflexion of the foot.
Normal variations in the pediatric cardiovascular system are:
-acrocyanosis
-S3 sounds
-heart rate more rapid
-sinus arrhythmia
____ is increased heart rate on inspiration and decreased heart rate on expiration.
Sinus arrhythmia
____ is when children have blue hands and feet but a pink body.
Acrocyanosis
Cardiovascular variations in elderly adults include:
-S4 heart sounds
-distal arteries diff. to palpate
-blood vessels prominent
-varicosities common
-decreased cardiac output and strength of contraction
-increased blood pressure
-hardened arteries
Varicose veins in elderly adults are common because
ineffective veins allow backflow.
Distal arteries are difficult to palpate in elderly adults because they have
inadequate circulation.
Breast self exams should be completed ____.
monthly after the menstrual period.
Mammograms should be started at
35-39 years for a baseline and yearly after age 40.
_____ is enlargement of breast tissue in men.
Gynecomastia
Breast growth generally begins around age ___. Menarche usually happens with ___ yrs.
8
two
Organs in the RUQ are:
liver
gallbladder
duodenum
head of pancreas
right adrenal gland
upper lobe of right kidney
hepatic flexure of colon
section of ascending colon
section of transverse colon
Organs in the LUQ are:
left lobe of liver
stomach
spleen
upper lobe of left kidney
pancreas
left adrenal gland
splenic flexure of colon
section of transverse colon
section of descending colon
Organs in the RLQ are:
lower lobe of right kidney
cecum
appendix
section of ascending colon
right ovary
right fallopian tube
right ureter
right spermatic cord
part of uterus
Organs in the LLQ are:
lower lobe of left kidney
sigmoid colon
section of descending colon
left ovary
left fallopian tube
left ureter
left spermatic cord
part of uterus
When assessing the abdomen, be sure to ___ and ____ before ____ or ____.
inspect and auscultate
palpating or percussing
When assessing the abdomen, the ___ position is best.
supine
On inspection of the abdomen you should not see
peristalsis, pulsations, masses.
____ are stretch marks; breakdown of elastic tissue.
Striae
The normal percussion sound of the stomach is _____.
tympany
Use the ___ of the stethoscope to auscultate the abdomen.
diaphragm
____ bowel sounds are described as gurgling and occur every 5-20 seconds.
Normal
____ bowel sounds are soft and infrequent. They may be due to an obstruction or surgery.
Hypoactive
____ bowel sounds are high pitched, loud, rushing sounds that are very frequent.
Hyperactive
_____ are bowel sounds.
Borborygmi
When auscultating the abdomen go in the following order:
RLQ, RUQ, LUQ, and LLQ
Cannot document absent bowel sounds unless you listen for ____ minutes in each quadrant.
3-5
Abdominal variations in pediatrics are:
-pot belly
-visible peristaltic waves
-liver and spleen more easily palpated
Abdominal variations in geriatrics are:
decreased
-bowel sounds
-muscle tone
-motility in GI tract
-absorption of oral meds
and
Increased incidence of colon cancer
The musculoskeletal system includes:
bones, muscles, tendons, cartilage, and ligaments
____ disorders often manifest with the musculoskeletal system.
Neurologic
3 things we assess with the the musculoskeletal system are:
ROM, muscle tone, and muscle strength
The positions used when assessing the musculoskeletal system are
standing, sitting, and supine
On inspection of the musculoskeletal system look at the
symmetry, gait, posture, and balance
Palpate parts of the musculoskeletal system for
tenderness and obvious enlargement
___ is the condition of the muscle at rest.
Tone
___ is assessed by having the patient move against resistance.
Strength
Abnormal findings of the muscular assessment include:
-atrophy
-hypertrophy
-tremors
-flaccidity
-ataxia
-decreased ROM
-selling, pain
contractures
____ is muscle wasting.
Atrophy
____ is an increase in muscle size.
Hypertrophy
____ are involuntary muscle movement.
Tremors
_____ is muscle weakness.
Flaccidity
_____ is clumsiness; lack of coordination.
Ataxia
_____ are permanent shortening of a muscle.
Contractures
____ tremors become more apparent when the individual attempts a voluntary activity.
Intention
____ tremors are more apparent at rest and diminish with activity.
Resting
____ is bone rubbing against bone.
Crepitation
11 joint movements are
extension
flexion
abduction
adduction
supination
pronation
circumduction
inversion
eversion
hyperextension
rotation
____ is decreasing the angle of the joint. ex. bending elbow
Flexion
____ is increasing the angle of the joint. ex. straightening of the elbow
Extension
____ is further extension or straightening of a joint. ex. bending the head backwards
Hyperextension
____ is movement of the bone away from the midline of the body.
Abduction
____ is movement of the bone toward the midline of the body.
Adduction
____ is movement of the bone around its central axis.
Rotation
____ is movement of the distal part of the bone in a circle while the proximal end remains fixed.
Circumduction
_____ is turning the sole of the foot outward by moving the ankle joint.
Eversion
_____ is turning the sole of the foot inward by moving the ankle joint.
Inversion
____ is moving the bones of the forearm so that the palm of the hand faces downward when held in front of the body.
Pronation
____ is moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body.
Supination
Pediatric muscular variations include:
hip dysplasia
lordosis (sway back)
genu varum (bow legged)
scoliosis (curvature of spine)
_____ or sway back is accentuation of the cervical or lumbar curvature associated with muscular dystrophy but may be normal during pubertal growth spurt.
Lordosis
____ is called bow legged.
Genum varum
____ is a lateral curvature of the spine.
Scoliosis
Skeletal variations in geriatric patients include:
-loss of muscle mass and strength
-decreased ROM
-decreased bone density
-decreased height
-kyphosis
-osteoarthritic joint changes
____ is hump back.
Kyphosis
Osteoarthritic joint changes happen when ____ wears away.
cartilage
____ is movement of the bone toward the midline of the body.
Adduction
____ is movement of the bone around its central axis.
Rotation
____ is movement of the distal part of the bone in a circle while the proximal end remains fixed.
Circumduction
_____ is turning the sole of the foot outward by moving the ankle joint.
Eversion
_____ is turning the sole of the foot inward by moving the ankle joint.
Inversion
____ is moving the bones of the forearm so that the palm of the hand faces downward when held in front of the body.
Pronation
____ is moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body.
Supination
Pediatric muscular variations include:
hip dysplasia
lordosis (sway back)
genu varum (bow legged)
scoliosis (curvature of spine)
_____ or sway back is accentuation of the cervical or lumbar curvature associated with muscular dystrophy but may be normal during pubertal growth spurt.
Lordosis
____ is called bow legged.
Genum varum
_____ is clumsiness; lack of coordination.
Ataxia
_____ are permanent shortening of a muscle.
Contractures
____ tremors become more apparent when the individual attempts a voluntary activity.
Intention
____ tremors are more apparent at rest and diminish with activity.
Resting
____ is bone rubbing against bone.
Crepitation
11 joint movements are
extension
flexion
abduction
adduction
supination
pronation
circumduction
inversion
eversion
hyperextension
rotation
____ is decreasing the angle of the joint. ex. bending elbow
Flexion
____ is increasing the angle of the joint. ex. straightening of the elbow
Extension
____ is further extension or straightening of a joint. ex. bending the head backwards
Hyperextension
____ is movement of the bone away from the midline of the body.
Abduction
____ is movement of the bone toward the midline of the body.
Adduction
____ is movement of the bone around its central axis.
Rotation
____ is movement of the distal part of the bone in a circle while the proximal end remains fixed.
Circumduction
_____ is turning the sole of the foot outward by moving the ankle joint.
Eversion
_____ is turning the sole of the foot inward by moving the ankle joint.
Inversion
____ is moving the bones of the forearm so that the palm of the hand faces downward when held in front of the body.
Pronation
____ is moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body.
Supination
Pediatric skeletal variations include:
hip dysplasia
lordosis (sway back)
genu varum (bow legged)
scoliosis (curvature of spine)
_____ or sway back is accentuation of the cervical or lumbar curvature associated with muscular dystrophy but may be normal during pubertal growth spurt.
Lordosis
____ is called bow legged.
Genum varum
Assessment of the neurologic system includes:
-mental status
-cranial nerve function
-motor function
-sensory function
-reflexes
Neurologic System Assessment
Position-

Equipment-
Position- sitting

Equipment- pen light and reflex hammer
____ is difficulty swallowing.
Dysphagia
Oriented times 3 means
patient knows person, place and thing
Levels of consciousness
awake and alert
lethargic
stuporous
comatose
A person who is ____ is sluggish and sleepy.
lethargic
A person who is ____ sleeps most of the time, is hard to awaken, confused, and will respond to pain with purposeful movements.
stuporous
A person who is ____ cannot be aroused even with painful stimuli.
comatose
The Glasgow Coma Scale assesses the ____. A score of ___ or less is indicative of a coma.
level of consciousness

7
The Glasgow Coma Scale assesses 3 things:
eye opening
motor response
verbal response
When a person loses orientation or level of awareness, the first thing to go is
time. Then place and last is person.
Language is controlled by the _____.
cerebral cortex
Assessment of mental status is accomplished thru looking at
language
____ is a disorder of language ability.
Aphasia
____ aphasia means that the person can understand what is said but cannot write or speak to communicate effectively.
Expressive
____ aphasia means the person does not understand written or spoken words. They have impaired comprehension.
Receptive
You can assess expressive aphasia by
telling the patient to do something.
Assessment of motor function includes:
balance, gait, and coordination
Assessment of sensory function includes
response to pain, light, touch, and vibration
5 reflexes that are assessed are
biceps
triceps
patellar
achilles
babinski
The ___ reflex is tested at the inner bend of the arm.
biceps
The ____ reflex is tested at the back side of the elbow.
triceps
The ____ reflex is at the knee.
patellar
The ___ reflex is at the ankle.
achilles
The ____ reflex is on the bottom of the foot.
Babinski
A normal Babinski is when the
toes curl.
Reflex of 0 means
no reflex response
Reflex of +1 means
minimal activity
Reflex of +2 means
normal response
Reflex of +3 means
more active than normal
Reflex of +4 means
maximal activity
Additional pediatric reflexes are:
rooting
grasp
startle (Moro)
positive Babinski
Parachute
Additional pediatric reflexes usually disappear by
4 months
The positive Babinski reflex disappears
after a baby starts to walk.
Motor control in pediatrics occurs ____.
cephalocaudaly
Geriatric lifespan variations in regards to reflexes, motor control and sensory function are:
-slower thought processes
-short term memory loss
-decreased sensory abilities
-slower coordination and voluntary movement
-decreased reflex responses
-confused in unfamiliar surroundings
-slower, wider based gait
-senile tremors
History of female genitalia assessment includes
-menstrual history
-sexual and pregnancy history
-vaginal discharge, itching, and pain on urination
-history of reproductive/genital cancer
-smoking
pelvic exam/pap smear
Female genitalia is assessed thru
inspection and palpation
History of male genitalia assessment includes
-difficulty urinating/incontinence
-erectile dysfunction
-discharge, STD's
-contraceptive use
-prostrate cancer
-frequency of rectal exams and testicular self exams
The ____ should be at the head of the penis.
urinary meatus
The ____ reflex is the testes response to retract into the inguinal canal when in contact with cold or touch.
cremasteric
____ is an abnormal collection of fluid in the scrotal sac.
Hydrocele
____ is abnormal dilation of a vein within the spermatic cord.
Varicocele
____ is when the urinary meatus is on the underside of the penis head.
Hypospadias
____ is when the urinary meatus is on the upperside of the penis head.
Epispadias
The testes and ___ scrotal sac are usually lower than the other side.
left
Pediatric genital variations in females include:
- vaginal discharge
-pseudo-menstruation
-enlarged labia and clitoris
Pediatric genital variations in males include:
-placement of urinary meatus
-foreskin tight at birth
Geriatric genital variations in females include:
-decreased vaginal secretions
-atrophy of urethra, fallopian tubes, and ovaries
-cervix and uterus decrease in size
-need assistance with lithotomy exam
Geriatric genital variations in males include:
-decrease penis size
-prostate gland enlarges
-may experience frequency, nocturia, dribbling, and difficulty beginning stream
Elderly males may experience frequency, dribbling, nocturia, and difficulty beginning stream which are all related to ____ and symptoms of ____.
enlargement of the prostate

symptoms of BPH or prostate cancer
Olfactory (I)
sensory

ask client to close eyes and identify smells
Optic (II)
sensory

Snellen type chart, check visual fields, and opthalmoscopic exam
Oculomotor (III)
motor

assess ocular movements and pupil reaction
Trochlear (IV)
motor

assess ocular movements
Abducens (VI)
motor

assess directions of gaze
Trigeminal (V)
sensory

elicit blink reflex, light sensation and deep sensation
Facial (VII)
motor and sensory

ask client to smile, frown, raise eyebrows, puff cheeks, close eyes tightly, and identify tastes
Acoustic (VIII)
sensory

Romberg test and use tuning fork
Glossopharyngeal (IX)
motor and sensory

move tongue and recognize tastes at back of tongue
Vagus (X)
motor and sensory

assess with IX for hoarse speech
Accessory (XI)
motor

shrug shoulders and turn head side to side against resistance
Hypoglossal (XII)
motor

protrude tongue at midline and move side to side