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31 Cards in this Set
- Front
- Back
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Standing position is used during assessment to assess |
posture, balance, and gait |
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What is the supine position and when is it used to assess something |
it is when the patient is lying flat on their back with their palms on the mat. It is used to assess vital signs, head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses |
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What is the Sims Position and when is it used for an assessment |
it is when the patient lies on either side, both knees flexed with the upper leg slightly higher. It is used to assess the rectum or vagina |
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What is the lithotomy position and when is it used for assessment |
it is when the patient is on their back and have their heels on stirrups and their butt at the end of the table. it is used to assess the vagina and rectum. |
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when is the sitting position used for assessment |
vital signs, head, neck, anterior/ posterior thorax, lungs, hearts, breasts, upper extremities |
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What is the dorsal recumbent position and when is it used for assessment |
this is when the patient lies on their back with their knees bent and their legs slightly seperated. It is used to assess head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses. NOT abdominal assessment |
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What is the Prone position and when is it used for testing |
it is when they are lying with their stomach on the mat and their head turned towards a side, used to assess hip joint and posterior thorax. |
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What is the knee-chest position and what is it used to assess |
this is when the patient kneels with their butt up in the air and their head on the mat. used to assess anus and rectum |
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when are the palmar (fingertips) and dorsal (back of hand) used during palpation |
palmar is used to assess texture, vibration, fluid, size, or consistency of mass. dorsal is used for temperature |
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what are the seven characteristics to look at when assessing masses |
Shape, size, consistency (firm, spongy, etc.), surface (smooth, nodular, etc.), mobility (fixed or nonfixed), tenderness (degree of tenderness), pulsatile (whether or not it can be felt) |
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what is percussion used to assess |
location, shape, size, and density of tissues |
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auscilation |
listening with a stethoscope to sounds produced in the body |
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four characteristics of auscilation that should be assessed |
pitch, loudness, quality (gurgling/ swishing), duration |
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Assessing the head |
Head: Size/ shape of head, distribution/ color of hair Face: facial expressions, rashes, lesions, symmetry Cranial nerve seven: smile, show teeth, blow out cheeks, raise eyebrows, close eyes tight Cranial nerve five: lightly touch face and ask where they feel it palpate temporal artery: between eye and ear (should be non tender and elastic) |
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Assessing the eyes |
external eye: abnormality with eyelashes, eyelids/ condition of eye pupillary reaction to light: focus on far away object and flash light to see if they contract Accommodation of pupils: focus on far point and near point to see if the pupils constrict and eyes converge |
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Assessing the ears |
External: lumps, lesions, discoloring. palpate oricle mastoid process for tenderness (jaw line next to ear) check for changes in hearing |
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Assessing nose |
external: color, shape, consistency, tenderness (palpate) patency of airflow through nostrils: ask patient to block one side of nose with finger and take a deep sniff in and then check the other one. ask about problems with sense of smell |
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Assessing mouth and throat |
need tongue depressor and pen light check lips for color, consistency, lesions check teeth, gums, and pupil mucosa check rise of uvula check cranial nerves nine and ten by checking gag reflex with tongue depressor changes in sense of taste |
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Assessing the neck |
swelling, lesions, symmetry, masses range of motion, turn head, touch chin to shoulder, right ear to right shoulder, chin to chest and ceiling check trachea- put finger in notch and make sure everything is symmetrical check thyroid gland with fingers and thumb check artery sounds with stethoscope to look for blowing or swooshing sounds while breath is being held |
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assessing arms, hands, and fingers |
skin coloration, lesions, texture, masses have them put their hands together and then straight over head with their arms straight, then flex elbows and put arms behind head and then straighten arms and put palms up and down palpate brachial and radial pulse check ulnar pulse range of motion of wrist muscle strength: push against hands palpate hands for temperature and check nail beds, capillary reflexes on finger nails range of motion in fingers |
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Assessing posterior and lateral thorax |
position, spinal abnormalities, ask for shortness of breath, check posture while breathing, check tenderness chest expansion at T9 and T10- thumbs should move about 5-10 cm apart check for tone using percussion check for wheezes, and other abnormalities in a zig zag |
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Assessing the Anterior Thorax |
scope of ribs, skin, barrel chest, intercostal spaces |
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Bradykinin |
vasodilator, increases capillary permeability and constricts smooth muscle, present at injury site for pain transduction and triggers release of histamine. Togehter, bradykinin and histamine lead to the production of redness, swelling, and pain in an inflammatory response |
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substance p |
sensitizes receptors on nerves to feel pain and increase firing rate of neurons |
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prostaglandins |
hormone-like substances that send info about pain to CNS |
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A-delta fibers |
fast transmitting acute/ localized pain |
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C-fibers |
smaller than A-delta, slow conducting, convey diffuse, visceral pain/ burning/ aching |
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What is the difference between endorphins and enkelphins and what is their role in pain |
they are analgesics so they reduce pain and anxiety. Enkalphins are found in the brain (like endorphins), but also in the spinal cord. they are less potent than endorphins. enkalphins are thought to block pain by inhibiting substance P from being released. |
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Gate Control Theory of Pain |
small diameter nerve fibers conduct excitatory pain stimuli and large diameter nerve fibers inhibit transmission of pain. Gating mechanism in dorsal horn of spinal cord. When too much info is sent through spinal cord, signals are interrupted as if closing a gate. Experiences and behaviors can affect the gating. |
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intractable |
pain resistant to therapy and persists despite interventions |
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neuropathic pain |
phantom limb, for example. pain that occurs, despite a normal reason for it |
