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76 Cards in this Set
- Front
- Back
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Nurse obtains from observation the client has a broken arm. |
Primary objective data |
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CNA tells you the client's said her shoulder is sore. |
Secondary subjective data |
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Physical therapist notes indicate the client can not sit up. |
Secondary objective data |
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The client tells the nurse they have a headache |
Primary subjective data |
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Preliminary actions |
Introduce self
Identify patient (Name/DOB) Gather supplies Explain procedure Wash hands Provide privacy |
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Good practices while performing assesment |
Offer toilet
Comfortable position Comfortable bed height Good lighting/warmth Mute TV/Radio Auscultate bare skin Holding stethoscope with “V” positioning Documentation |
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Techniques used in physical assessment |
Inspection Palpation Auscultation Percussion |
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Percussion sounds |
Flate Dull Resonance Tempany (musical) |
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Bell of stethescope tranmists |
Low frequency |
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Pain scale |
Mild pain: 1-3
Moderate pain: 4-6 Severe pain: 7-10 |
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Neurological assessment focus on?
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•Level of Consciousness
•Sensory Deficits •Movement of Extremities (MOE) •Grips •Gait •Speech •Pupils |
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Thigh Blood Pressure (bladder of cuffmust be over the posterior _______ artery for the reading to be accurate)
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popliteal |
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If there is a difference of ____mmHg between arms this needs to be reportred to the physican |
10 |
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Normal Temp is ___.__F - 99.5F
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96.8 |
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Pulse sites |
Temporal Carotid Apical Brachial Radial Femoral Popliteal Posterior tibial Dorsalis pedis |
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Pulse Evaluation: Quality or amplitude
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0 Absent (Doppler)
1 +- Thready/Weak 2 +- Normal 3 +- Increased 4 +- Bounding |
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Capillary refill (Delayed return of color-arterial insufficiency)
< 3 sec in adults < __ sec in children |
2 |
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Cardiacoutput
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Volume of blood pumped into arteries |
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PMI |
Point of maximum impulse (apical pulse) |
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Pulse volume
Pulse rhythm Pulse deficit * |
Strenght or amplitude Pattern (equal rate) Difference between two pulse sites |
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Factors affecting pulse |
Age Sex Exercise Rest and Temperature Medication Hypovolemia/dehydration (loss of blood/vol) Stress Position Pathology (Electrolyte imbalance) |
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Head assesment |
•Hair •Scalp •Ears •Nose •Eyes •Lips •Mouth •Tongue |
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Pupil Abnormalities
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Normal size of pupils 3-7mm
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Eupnea |
Good breathing |
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Soft intensity, low pitched “gentle sighing sound” (5:2 ratio) Best heard at base of lungs
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Vesicular
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Moderate-intensity and moderately pitched “blowing sound” (1:1 ratio) Best heard 1st and 2nd ICS
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Broncho-vesicular
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High-pitched, loud, “harsh sound" (1:2 ratio) Best heard anteriorly over the trachea (also called tracheal breath sounds)
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Bronchial
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Caused by fluid that has leaked in the airways. They are characterized as discontinuous high pitched bubbling sounds |
Crackles (formally known as "Rales") |
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Typically associated with secretions that are obstructing the larger airways. This causes a lower pitched vibrating sound on auscultation that is similar to snoring. May clear with cough. |
Sonorous wheeze (rhonchi) |
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Characterized by a low pitched grating sound similar to the sound of walking on snow.
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Pleural Rub
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High pitched vibration caused by bronchispasm or asthma |
Wheezes |
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formed accidentally or in an unusual anatomical position.
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adventitious |
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O 2 Sat % < 93%
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abnormal |
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Deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure.
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Kussmaul Respiration
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Labored or difficult breathing |
Dyspnea
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Shortness of breath (dyspnea) that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair.
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Orthopnea
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Slower than normal breathing < 10 bre/min |
Bradypnea |
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Mixture of saliva and mucus coughed up from the respiratory tract
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Sputum |
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Measures patients likleyness of developing a pressure ulcer |
Braden Scale |
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Exudate |
drainage |
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Bruises
Initially appears ________ looking Day 1-2: blue or purple Day 6: _______ Day 8-9: yellowish-_________ 2-3 weeks: normal color |
Reddish Greenish Brown |
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Serous |
watery yellow drainage |
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Sanguineous |
More of a pure blood appearance |
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consisting of, containing, or discharging pus |
Purulent |
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Containing or relating to both blood and the liquid part of blood (serum). Watery pink drainage |
Serosanguineous |
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< 1cm in diameter.
Small, raised, solid pimple or swelling, often forming part of a rash on the skin and typically inflamed but not producing pus. |
Papule
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(ex. port wine or brown birth marks, freckles, flat moles, petechiae) they are flat and are 1 mm-1cm
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Macule
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are dry lesions > 1 cm (ex. psoriasis)
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Plaques
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(ex. mosquito bite or hives) is a reddened collection of fluid (edema of the skin), irregular in shape
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Wheal
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are elevated solid, hard masses that extends deep into the dermis (0.5-2 cm - 0.2-0.8 in)
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Nodules
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are larger than 2cm and may have an irregular border (malignant melanoma).
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Tumors
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thin translucent mass that is filled with serous fluid or blood. <0.5 cm (0.2 in.) (ex. Herpes simplex, early chicken pox, small burn blisters
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Vesicle (bulla's are large in size)
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are vesicles filled with pus.
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Pustule
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pale due to inadequate circulation
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Pallor
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blueness
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Cyanosis
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Yellowing of the skin and sclera of the eyes
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Icteric (Jaundice)
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wasting away of the muscle
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Atrophy
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skin loss extending into the dermis or subcutaneous tissue
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Ulcer
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area of fibrous tissue after an injury such as a cut (laceration)
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Scar
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to scratch, abrade or strip off the skin by physical means, linear erosion
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Excoriation
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hair loss/ baldness
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Alopecia
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Nail beds: should be 160 degree angle
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Clubbing
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(180 degree or greater) long term lack of oxygen.
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Clubbing of fingers
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Spooning of the nail may indicate _____ deficiency _________
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iron
anemia |
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an unintentional (involuntary), rhythmical alternating movement of a muscle. Alternating contraction and relaxation of a muscle
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Tremors
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twitching of muscle fibers
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Fasciculation
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redness |
erythema |
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Enlardeg pupils |
Mydriasis |
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Constricted Pupils |
Miosis |
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_________ auscultation involves the use of a stethoscope to amplify the sounds from within the body, like a heartbeat.
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indicrect |
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Vomiting casuses heart rate to.... |
drop (vegas nerve) |
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a region of injured tissue or skin in which blood capillaries have been ruptured; a bruise
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Contusion |
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is a wound caused by superficial damage to the skin, no deeper than the epidermis.
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abrasion |
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Meaning both sides |
Bilateral |
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Chest |
thoracic |
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Eye test |
Direct pupil + concensual response Pen near to far 6 point extracellular muscle test |
