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66 Cards in this Set
- Front
- Back
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Identify the aspects of the physical health examiniation
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1.The nursing health history
2 the physical examination |
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A physical examination can be of what type
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1 complete assesment
2 examination of the body system 3 examination of the body area |
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what is the purpose of physical examination
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1 to obtain baseline data about the clients fucntional abilities
2 to supplement, confirm refute data obtained in the nursing history 3 to obtain data that will help establish nursing diagnosis and plan of care 4 to evaluate the physiologic outcomes of health care an thus the progress of a clients health problem 5 to make clinical judgements about a clients health status 6 to identify areas for health promotion and disease prevention |
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what should you do before starting an assignment
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prepare the environment, positioning, draping and intrumentation with client
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4 methods of examining
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1 inspection=visual examiniation, assessing by using the sense of sight
2 palapation-is the examiniation of the body using the sense of touch, pads of the fingers are used because their concentration of nerve endings, make them highly sensitive to tactile discrimination 3 percussion-is the act of striking the body surfaces to elicit sounds that can be heard or vibrations than can be felt, percussion is used to determine the size and shape of internal organs by establisihing their borders(direct and indirect 4 ausculation=the process of listening to sounds produced within the body |
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what are the two types of palpation
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light and Deep
light-should always precede deep paplaption, becasue heavy pressures on the fingertips can dull the sense of touch deep paplation-done with two or one hand |
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what are the two types of percussion
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indirect and direct
indirect is the striking of an object held against the body are to be examined(finger) direct=the nurse strikes the the area directly with the pads of 2, 3 or 4 fingers pads or with the pads of middle finger |
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what are the 5 sounds elicited from percussing
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Flatness-extremely dull soundproduced by very dense tissue, such as muscle or bone
Dullness-thudlike sound produced by dense tissue such as the liver, spleen or heart Resonance-hollow sound such as that prodyced by lungs filled with air Hyperresonnance- not produced in the normal body,it is described as booming and can be heard over an emphysematous lung Tympany=musical or drumlike sound produced from an air filled stomach |
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Ausculating sounds are described according to what 4 sounds
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Pitch-the frequency of the vibrations(# of vibrations per second)
Intensity=(amplitude)refers to the loudness or softness of a sound Duration=length(long or short) Quality-is a subjective description of sound, ie whisteling, gurgling or snapping |
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How are health assessments done or conducted
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Health assessments start with a general survey that involves observation of the clients general appearance and mental status, and measurements of vital signs, height,& weight
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what does the integument include
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skin, hair and nails
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what does assessment of skin include
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it involves inspection and palpation
pallor-is the result of inadequate circulation blood or hemoglobin and subsequent reduction in tissue oxygenation cyanosis-(bluish tinge) is most evident to the nail beds, lips and buccal mucosa jaundice-(yellowish) first evident in sclera of eyes and in mucous membranes of skin erythema-redness associated with a variety of rashes vitiligo-seen as pathces of hypopigmented skin, caused by destruction of melanocytes edema-presence of excess interstitial fluid |
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describe different types of primary skin lesions
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Macule, patch-unelevated changes in color(freckles, measles, petechia, flat moles.
Nodule(tumor)=elevated solid hard mass that extends deeper into the dermis than a papule cyst=fluid filled or semisolid in dermis or subquataneous tissues papule=circumscribed, solid, elevation of skin, ie warts, acne, pimples elevated moles pustule=vesicle or bulla filled with pus. ie acne, vulgaris impetigo plaque=larger than 1cm psoriasis, rubeola wheal-reddened, localized collection of edema fluid, irregular in shape |
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Describe secondary skin lesions
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atrophy-translucent dry paperlike sometimes wrinkled skin (ie stria,stretch marks, aged skin)
erosion=wearing away of the superficial epidermis causing moist shallow depression( ie scratch marks, ruptured vesciles) ulcer=deep irreguraly shaped area of the skin, may bleed(ie decubitus ulcers, chancres) fissure-linear crack with sharp edges extending into the dermis(cracks at corner of mouth and hands) scar=flat irregular shaped are of connective tissue left after a lesion or wound ghas healed (healed surgical wounds, healed acne) |
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describe the scale for detecting edema
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1+ barely detectable 2mm
2+ indentation of 2-4 mm 3+ indentation of 5-7mm 4+ indentation of more than 7mm |
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ways of describing skin lesions
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Type or structure-primary or secondary
size shape & texture=size in mm, round or irregular or depressed solid soft or hard color-may be no discoloration distribution-described accourding to the location of the lesions in the body and symetry or asymetry of findings in relative to other body areas configuration-araingments of lesions in relation to each other |
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Describe the nails
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the nail is normally colorless and conves curve and the angle between the nail bed is normally 160 degrees , the nail bed is highly vascular a characteristic that accounts for its pink color in white people, blue tints reflect cyanosi and pallor may reflect poor arterial circulation
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what is clubbing
What is a blanche test |
condition in which the angle between the nail and the nail bed is 180 degrees or greater, clubbing may be caused my long term lack of oxygen
Blanche test-can be carried out to test the capillary refill, peripheral circulation, normal nail bed capillaries blanche when pressed but quickly turn pink or their usual color when pressure is released |
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what does the nurse do during normal assessments of the head
what is normocephalic= |
the nurse should inspect, palpate, simutaneoulsy and also ausculate
normacephalic is the normal head size |
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eyes and vision
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examiniation fo the eyes include s assessment of visual acuity-teh degree of detail an eye can discern in an image, ocular movement
visual fields-the area an individual can see when looking straight ahead, and external structures |
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what is conjuctivitis
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inflammation of the bulbar and palpebral conjuctivca(may result from foreign bodies, chemicals, allergins , agents, bacteria, or viruses
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what is cataracts-
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tend to occur in those over 65 this opacity of the lens or its capsule which block light rays is frequently moved removed and replaced by a lens implant
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what is glaucoma
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disturbance of the circulation of aqueous fluid which can increase in intracoular pressure, most frequent cause of blindness in people over 40
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assessing the eye structures Direct and consensual reaction to light
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*partially darken the roon
*ask client tolook straight ahead *use pen light or flashlight, approaching from the side *observe the response of the illuminated pupil, it should constrict *shine light on the pupil again and observe the respone of the other pupil it should also contrict |
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assessing the eyes, reaction to accomodation
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*hold an object about 10cm front he bridge of the nose
*ask the client to look first at the top of the object and then at the distant object behind the penlight *observe pupil response, pupils should constrict when looking at the near object and dilat when looking at the far object *next move the penlight toward the clients nose the pupils should converge to record normal assessments of pupils us the abbreviation PERRLA (Pupils equally round and react to light) |
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assessing the 6 ocular movements
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stand directly in front of client ask the client to hold head in a fixed position and follow movements of pen, in the 6 cardinal fields of gaze
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describe assessment of the ear
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includes direct inspection and palpation of the external ear,
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the ear is divided into three parts
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external, middle and inner ear
external ear=auricle or pinna the external auditory canal, and tympanic membrane lobule-landmarks of the auricle(earlobe) tragus-cartilaginous protrusion at the entrance to the ear canal |
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how do we hear
Sound transmission and hearing are complex processes. in brief, sound can be transmitted by air conduction or bone conduction |
1 a sound stimulates the external canal and reaches the tympanic memebrane
2 the sound waves vibrate the tympanic membrane and reache the ossicles 3 the sound waves travels fromt eh ossicles to the opening in the inner ear 4 the cochlea recieves the sound ibrations 5 the stimulus travels to othe auditory nerve(8th cranial nerve and the cerebral cortex Bone conducted sund transmission occurs when skull bones transport the sound directly to the auditory nerve |
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thorax and lungs
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assessing the thorax ans lungs in frequently critical to assessing th clients aeratin status
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what are the imaginery lines on the chest
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these lines help the nurse identify the position of underlying organs and to record abnormal assessments
Midsternal linevertical line running through the the center pf the sternum Midclavicular line-vertical lines running midpoint of the clavicle Anterior axillary line-vertical lines anterior axillary folds |
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what is the angle of lois
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it is the starting point for locating the ribs anteriorly, the junction b/w the body of the sternum and the manubrium
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what is the normal adult chest size
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in adults the thorax is oval, its anteroposterior diameter is half it's transverse diameter
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what are abnormal breath sounds
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adventitious breath sounds, ocurs when air passes throuogh narrowed airways or airways filled with fluid or mucous, or when the pleural linings are inflammed
4 types of adventitious breath sounds Crackling, (rales or crepitations like putting yor hair in b/w fingers and rubbing) gurgles,-continuous low pitched caorse gurgling harsh loud sounds pleural friction rubs-superficial grating or creaking sounds heard during inspiration and expiration wheezes-continous high pitched squeaky musical sounds |
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what are normal breath sounds
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Vesicular=soft intesnsity, low pitched, gentle sighing, created by sounds moving through smaller airways(bronchioles and alveoli
Broncho-vesicular=moderate intensity and moderate pitched blowing sounds created by air moving through larger airway(bronchi) Bronchial(tubular)=high pitched loud harsh sounds created by air moving through the trachea |
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what are 3 chest deformities
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Pigeon chest=a permanent deformity amy be caused by rickets
Funnel chest=a congenital defect opposite of pigeon chest, in that the sternum is depressed, abnormal pressur on the heart may result in altered function barrel chest=excessive convex curvature of the thoracic spine |
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describe the normal sounds of the heart
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the normal first 2 sounds are produced by closure of the valves of the heart
S1-occurs when the atrioventricualr(av) valves close (lub) these valves close when the ventricles hae been sufficiently filled , after the ventricles close empty their blood into the aorta and pulmonary arteries the semilunar valves close producing the second heart sound S2=Dub has a higher pitch than s1 and is also shorter these 2 sound occur within a second or less depending on the heart rate |
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associated with the heart sounds are systole and diastole
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systole=is the period in which the ventricles contract begins with S1 and ends at S2 systole is nornally shorter than diastole
Diastole=period in which the ventricles relax is starts with S2 and ends at the subsequent |
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where are the heart sounds best heard at
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the heart sounds are audible anywhere but are best heard over the aortic, pulmonic tricuspid and apical areas
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describe the juglar vein
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it drains blood from the head and neck directly into the superior vena cava and right side of heart
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describe neck veins
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normally external neck veins are sitended and visible when a person lies down, they are flat and not as visible when a person stands up because gravity encourages venouse drainage
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what organs are in the upper right quadrant
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liver gallbladder, right adrenal glands head of pancreas
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what organs are in teh right lower quadrant
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cecum, appendix, right ovary, part of uterus, right ureter, lower lobe of right kidney
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what organs are in the left upper quadrant
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stomach left lobe of liver, stomach, spleen, pancreas, left adrenal gland
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what organs are in the left lower quadrant
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lower lobe of left kidney, sigmoid coln, section of descending colon, left ovary, left fallopian tube, left ureter, part of ureter
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what are the major assesments in assessing mental
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language, orientation, memory, attenmtion span and calculation
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what is aphaisia
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any defects in or loss
of the power to express onself by speech, writing, or signs or to comprehend spoken or written language due to disease due to disease or injury of the cerebral cortex |
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what is a reflex
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an automatic response of the bodyto a stimulus, it is not voluntarily learned or conscoius
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what is the plantars reflex
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the planter reflex, also teh Babinski reflex is superficial, it may be absent in adults without pathology or overriden in voluntary control, use a moderatley sharp objuect, strock the laterla border of the sole of the clients foot, starting at the hell , observe the response
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what is the Glascow coma scale
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It is a test to tst levels consciusness, the faculties that are measured are eye opening, motor response and verbal response
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what is the sims position
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it is a side lying position with lowering arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow
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what is the supine positon
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back lying postion with legs extended with or without pillow under the head
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what is a prone position
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lies on abdomen with head turned to the side, with or without a small pillow
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what are the environmental issues that you should consider when prparing to physically examine the client
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positioning-important to consider clients ability to assume a position
Draping=drapes should be arrainged so that the area to be assessed is exposed and other body areas are covered instrumentataion=-all equipoment will be in clean in good working order and readily accessible |
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what are the aspects of general survey
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General survey that involves observation of the clients general appearance and mental status and measurement of vital signs, height, and weight, many components of the general survey are assessed while taking the clients health history, such as the clients body build, posture, hygiene and mental status
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assessing the ears
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assessment of the ears includes direct inspection and plapation of th external ear, inspection of the remaining parts of teh ear by an OTOSCOPE and determination og auditory acuity
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what is conduction hearing loss
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result of interrupted transmission of sound waves through the outer and middle ear structures
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what is sensorineural hearing loss
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reslut of damage to teh inner ear, the auditory nerve or the hearing center in teh brain
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what is mixed hearing loss
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combination of conduction and sesorineural loss
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describe steps when assessing a client abdomen
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* ask client to urinate, to empty bladder
*Inspect the abdomen for skin integrity *inspect the abdomen for contour and symetry *observe ab movements asscoiated with respiration, peristalis, or aortic pressure *observe the vascular pattern ausculate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs *percuss several areas in each quadrants to determine presence of tymphany and dullness *percuss liver to determine size *perform ligh palpations to detect areas of tenderness *perform deep palpations over quadrants, liver and bladder |
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what does the examination of the neurological system include
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*mental status
*level of consciousness *cranial nerves *reflexes *motor function *sensory function |
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in what position is the examination of prostate usually conducted
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in teh sims position
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what does the musculoskeletal system encompass
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the muscles, bones and joints
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what is a fasciculation
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an abnormal contraction(shortening) of a bundle of muscle fibers
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what is a tremor
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involuntary trembling of a limb or body part
tremors may invlove large groups or small bundles of muscle fibers Intention tremor=becomes more apparent when a person attempts a voluntary movement, like holding a cup of coffee restin tremor=more apparent when person at rest and diminishes with activity |
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what type pf adventitious breath can be cleared with a cough
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gurgles can be altered when coughing all over adventitious sounds may not be cleared with a cough cracles, wheezing, and friction rub
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