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57 Cards in this Set
- Front
- Back
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Elements of General Survey
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1, Level of consciousness (LOC)
2. Age Appears stated age or > or < 3. State of Health, appears good or chronic / acute illness. 4. Posture and gait. are they erect, slumped, slouched, do they shuffle, walk smoothy 5. Nutritional Status, 6 personal hygiene: clean, neat, describe clothing, any body odors 7. signs of distress: grimacing, anxious, labored breathing 8. facial expression: mood, affect, manner 9. mental status orientation- person place time Ox3 10 get hight weight and vital signs. |
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Level of Consciousness (LOC)
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awake, alert, drowsy, lethargic, responds to voice, responds to pain or non responsive.
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Nutritional Status
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well nourished, malnourished, obese, thin, emaciated, cache(extreme wasting)
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Physical Exam Techniques
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Inspection, palpation, percussion, auscultation
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Percussion
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Method by which the body is struck indirectly to elicit sounds. Sounds produced; flatness(bone); dullness(liver); resonance (lungs); hyper resonance (emphysema/lung); tympani(abdomen).
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Auscultation
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Listen to sounds in the body direct (use of ear) or indirect with a stethoscope. The diaphragm (flat) is used for high pitched sounds (breath, normal heart sound, bowel sounds). The bell is used for low pitched sounds (abnormal heart sounds, bruit)
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Parts of the Physical Assissment
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1. Integument- skin
2. Head and face 3. Eyes and vision 4. The ears 5. the nose and sinuses 6. The mouth and Oropharynx 7. The Thorax and the Lungs 8. Heart and Vascular System 9. The Abdomen 10. The Musculoskeletal System 11. Neurological System |
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Integumentary System
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1. color
2. moisture 3. temperature, 4. turgor 5. lesions/rashes 6. hair 7. nails |
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Skin Color
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Should be appropriate for skin tone. Abnormalities of skin color include pallor decreased Hbg supply - appears as a loss of red tones in dark skin, best seen in the nail beds, lips, oral mucous membranes. Cyanosis is blueness in light skin( decreased oxygenation) is seen as ash gray in dark skin central Cyanosis best seen in lips, buccal mucosa, and the tongue. Jaundice - yellow skin from liver disease due to increased bilirubin
erythema -redding of the skin inflammation and rashes. |
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Skin Moisture
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excessive sweating (diaphoresis); excessive dryness (elderly)
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Turgor
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Elasticity, hydration - assess on back of hand, poor turgor skin remains tented > 3 sec
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Lesion types
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Primary: Macule, papule, nodule, vesicle, bulla, pustule, wheal, plaque
Secondary: Scale, Scar, Fissure, Ulcer, Crust, Keloid |
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Macule
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Flat up to 1 cm in size - frekle
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Papule
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elevated, solid < 1cm - pimple wart
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Nodule
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Solid Mass Deeper than papule
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Vesicle
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Fluid filled, defined - blister, chickenpox
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Bulla
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large elevated, fluid filled - hives
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Pustule
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Pus fill < 1 cm - acne impetigo
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Wheal
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irregularly shaped fluid collection - hive
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plaque
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raised solid lesion
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scale
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dried fragment of cells - danfruff, psoriasis
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scar
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formation of fibrous tissue after healing
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fissure
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linear crack athlete's foot
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ulcer
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excavation of epidermis - stasis ulcer
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crust
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dried serum - impetigo - scab
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keloid
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hypertrophied scar - over grown scar
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Hair
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Assesses for distribution (hirsutism- excess hair), texture, infestation; fullness or loss (alopecia)
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Nails
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assess for shaped (clubbing) color(blanch test - cappillarty refilling in < 3 sec) texture, lesions
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Head and Face
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assessed by inspection and palpation
inspect size, symmetry, note any deformities ( Normocephalic is a medical term referring to a person whose head and all major organs of the head in a normal condition and without significant abnormalities) |
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eyes and vision
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Assess
1. External Structures a Eyelids, inspect for ability to blink; Position (ptosis -droopy eyelid) b. lesions, c conjunctive: palpebral(lid) color(pink) or lesions. d. sclera color white not red or yellow e. cornea assess for opacity or scratch f. pupil size, equality, shape, reaction to light and accommodation. PERRLA 2. Extra ocular Movement - 8 cardinal fields of gaze 3. visual fields - periphery 4. visual acuity - 20/20 5. internal structures -ophthalmoscope |
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Ears
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Exam includes inspection/ palpation of external parts, inspection of canal and drum with otoscope and auditory acuity
1. Auricle: inspect for position (pinna level with corner of eye) compare each side, look for lesions 2. canal - look for drainage. tympanic membrane requires otoscope 3. auditory acuity gross hearing my be assed by client's response to voice. Whisper test using 2 syllable words such as baseball. |
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Nose
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External nose inspect for any deviations in shape size color, flaring or discharge. check for patency (clear nasal passage way) check for sense of smell.
frontal /maxillary sinuses palate for tenderness. |
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Mouth
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Identify structures and assess for
lips - color, lesions; oral mucosa, color, lesions; teeth - # note any missing; gums - bleeding, snug to teeth, retraction; tongue - position, color and texture; tonsils - color, texture, size, pillars, posterior pharynx, soft palate, should have gag reflex |
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Neck
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identify and assess jugular veins, jugular venous distention- refers to pulsation in the interior jugular vein (or exterior) and is an indication of Rt heart failure. patient should be at 45degree angle and not the level of the pulsations relative to the sternal angle. ROM, Lymph nodes palpate and document andy enlarged or painful nodes. Identify carotid artery, trachea, trapezius, and sternocleidomastoid muscles
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Lungs
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Chest landmarks: imaginary lines for pupose of describing location. Anterior Midsternal, midclavicular, anterior anterior axillary, posterior; L or R scapular, Vertebgral. Lateral: posterior axillary, midaxillary and anterior axillary. identify 2nd and 5th intercostal spaces. To identify the 2 ics palpate the clavicle and follow it to the sternum; not the suprasternal notch. Follow the sternum down and palpate the bony ride(manubrium); move the finger laterally to find the 2nd rib (the 2nd rib is the first one felt since the 1st rib is beneath the clavicle ) the 2nd ics is the space beneath the 2nd rib.
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Posterior Thorax
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inspect shape and look for deformites. not the anteroposterior diameter compared with the transverse (NV 1:2)- AP diameter is < transverse or AP < T or 1'2. note any retraction of the interaspaces during inspiration found in emphysema, tracheal or laryngeal obstruction.
palpate - respiratory excursion place hands over lower thorax (10th rib) with thumbs adjacent to spine should separate 1 1/2 method of determining equal expansion of the lungs. |
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Anterior Thorax
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Inspect /count respirator rate (15 to 20 min) and note rhythm. not respiratory effort; use of neck muscles or abdominal breathing. observe intercostals spaces for retraction (obstruction) or bulging( emphysema)
palpation - may palpate for masses or crackling feeling. |
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Ausculation of Breath Sounds
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assess sounds that occurs as a result of the movement of air through the treachea, bronchi and alveoli. Sounds are assessed side to side anterior and posterior. The middle lobe is best assessed on the right side under the arm.
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Normal Breath Sounds
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Vesicular - inspiration > expiration; soft, low, heard in periphery and base of lungs
Bronchovesicular - inspiration = expiration; medium pitch, heard between scapula and anteriorly close to the sternum Bronchial - expiration = or > inspiration; loud and harsh; heard over tracha. Abnormal when heard elsewhere. |
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Adventitious (abnormal)
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breath sounds when air passes through narrowed airways filled with fluid or mucus; superimposed over normal breath sounds
Crackles - fine, high pitched crackling sounds; best heard on inspiration at the base caused by reinflation of the alveoli Rhonchi - low piched gurgling; moaning, snoring quality; heard between scapula and lateral to sternum; clears with coughing Wheeze- high pitched, squeaky; best heard on expiration; heard anywhere. |
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PMI (Point of maximal impulse)
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This is where the apical beat is assessed. The ventricles(apex) points forward, the apex of the left ventricle actually touches the anterior of the chest wall near the left midclavicular line at or near the 5th left ics.
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Land marks for assessment of the heart
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These areas correspond to the 4 vales in the heart.
Aortic Area - 2nd ics to the right of the sternum(closure of the pulmomic value loudest here) Pulmonic Area - 2nd ics to lerft of ternum (closure of the pulmonic valve loudest here. Erbs – 3rd ICS left of sternum Tricuspid - 5th ics left of the ternal border (closer of the tricuspid valve) Mitral - 5th ics left of the strenum just medial to MCL (closure of mitral valve) - when cardiac output is increased as in anemia, anxiety. HTN fever, the impulse may have greater force inspect for lift or heave. |
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Techniques of Assessment of the heart
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Inspection - look for lift at apex.
Auscultation - client should be assessed in supine position with head up to 45 deg.; examiner stands at right side. Use diaphragm for basic sounds; bell for murmurs and extra sounds. Identify the heart rate, rhythm, bell for murmurs aortic, pulmonic, mitral. |
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basic heart sounds
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S-1 - produced by the closure of the atrioventicular(av) valves, mitral and tricuspid - loudest at mitral area. The sound is a dull, low pitched "lub"
S-2 produced by closure of the aortic and pulmonic(semilunar) valves, is higher piched shorter and is the "dub" sound. Heard best at the base (aortic and pulmonic areas). S-2 is normally louder than S-1 |
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Systole/Diastole
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Systole begins with the 1st sound. As ventricles start to contract, pressure within exceeds the atria, shutting the mitral and ticuspid valves. Blood is forced into the great vessels. When the ventricles have emptied themselves the pressure in the aorta and pulmonary arteries force the smilunar valves shut(arotic/pulmonic) which is the 2nd sound and diastole (ventricular relaxation) begains
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Other heart sounds
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S-3 rapid fillng of the ventricle with blood; heard following S-2. can be normal in young adults and children; pathologic in elderly
S-4 - atrial contraction and thought to result from stiffened left ventricle directly precedes S-1 heard in the elderly. Extra sounds; snaps and clicks refer to valves; aortic and mitral steno sis, prosthetic valves. Murmurs: swishing or blowing sounds caused by Forward flow through a steno tic valve increased flow through a normal valve, backward flow through a valve that fails to close Murmurs should be identifed as systolic (between S-1 and S-2) or diastolic (between S-2 and S-1) Try to identify the grade of murmur; Grade 1 barely audible to grade VI loud and may be heard without the stethoscope If no other sounds are heard document that S-1, S-2 heard without extra sounds. |
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Peripheral Vascular System Assessment
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Assesment of BP, palpation of peripheral pulses, inexpection of jugular and peripheral vessels, pulses at temporal, coratid, apical, radial, brachial, femoral, popliteal, dorsalis pedis and anterior tibial Document pulse as 1+ to 4+ with 1+ being weak and 4+ being bounding 2+ being nomal what we expect. Look for JVD.
inspection of skin tissues to deteermin perfusinon to the extremities. Arterial insufficiency - cool extremity, dec or absent pulse, color changes, color pale Venous insufficiency - normal temperature, normal pulses, color changes; skin changes - edema, color dark. Deep Vein Thrombosis (DVT) - Horman's Sign: Knee flexed - pain in calf with dorsiflexion of foot. Not performed if pt is dx'd with thrombus. Edema fluid accumulation in the tissues assess by pressing firmly iwth the thumb - usually over shin or medial maleoulus of foot. graded on scale of 1+ to 4+ 1+ dissapears imediatly, 2+ 10 sec to dis, 3+ greater then a min 4+ 2 to 5 mins |
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Abdomen division for assesment
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done by dividing the abdomen into quadrants or into 9 sections. Quadrants- imaginary lines crossing tat the umbilicus. RUQ, LUQ, LLQ & RLQ
9 sections terms most often used are epigastric, umbillical, right and left inguinal, suprapugic. Organs in each quadrant RUQ: liver gall bladder, duodenum, colon, head of pancreas. LUQ: stomach, Spleen, Colon, Pancreas. RLQ: appendix, overy, urethra, kidney, colon, uterus LLQ: colon, ovary, urethra, kidney, uterus |
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Assessing the Abdomen
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order of assessment inspection, auscultion, percussion, palpation
Skin look for scars, rashes, lesions, striate, vascularities Conture - is it flat, rounded, protuberant, scaphoid(concave); distended, the 6F's: flatus, fetus, fat, fluid, feces, and fatal groth. Pulsation usually the abdominal aorta Auscultion: to assess bowel sounds, vascular sound; in pregnancy, FHT's are heard Frequancy of bowels sounds approx 5-20/min listen 3-5 min before reporting that they are absent. Describe what you hear as audible diminished- hypoactive-absent- hyperactive, borborygmi-really noisy. Percussion: to identify organ size and detect fluid, gass or masses. Palpation: to detect tenderness, distention (ascities vs flatus), pressence of masses(bladder)? light palpation - use fingertips with fingers together in a light dipping motion (1/2- 1" deep) |
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Bruit
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is the term for the unusual sound that blood makes when it rushes past an obstruction in an artery usually a blowing or sishing sound when the sound is auscultated with the bell portion of a stethoscope.
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stenosis
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is an abnormal narrowing in a blood vessel or other tubular organ or structure. It is also sometimes called a "stricture" (as in urethral stricture).
This of the vascular type are often associated with a noise (bruit) resulting from turbulent flow over the narrowed blood vessel. This bruit can be made audible by a stethoscope |
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Ascites
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The abnormal accumulation of fluid in the peritoneal cavity
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Ileus
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Obstruction of the intestine due to it being paralyzed. The paralysis does not need to be complete to cause ileus, but the intestine must be so inactive that it prohibits the passage of food and leads to blockage of the intestine
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Musculoskeletal System
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Assessment completeness depends on the needs and problems of the client.
Muscles are inspected for stength tone, size and symmetry. Strenght graded on a 0-5 scale. paresis- impaired strenght hemi paresis weekness on one half of the body check bones for normalcy and form joints for tenderness, swelling, ROM crepitation(gradieness)and nodules. Total body compare one side with the other should be symmetrical: note gross deformities posture - head balanced midway between sholders, shoulders aligned with hiips, hips over ankles Back Contour - normally the cervical spine is concave, the thoracic spine is convex, the lumbar spine concave. Note any deformities: Kyphosis- convex curvature of the thoracic spine; Scoliosis- lateral deviation of the spine Lordosis- exaggerated concavity of the lumbar spine gait noral is balanced, coordinated walking movements Extremities- side to side, compare length, muscle condition. look for atrophy(wating away); hypertrophy(increase in size) Note contractures - where flexor muscles are stronger than the extender muscles. Tone Slight residual tention- assessed by slight resistance to passive stretch Muscle Strenght- level of active movement against resistance- grips or push/pull of elbow |
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Glasgow Coma Scale
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objective numeral scale for measurement of consciousness. Measures eye opening, verbal response and motor response. The Higher the score the more normal the level of functioning.
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Babinski's reflex
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occurs when the great toe flexes toward the top of the foot and the other toes fan out after the sole of the foot has been firmly stroked. This is normal in younger children, but abnormal after the age of 2.
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Neurological system
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1. Level of Consciousness
2. Mental Status 3. Cranial Nerves 4. Reflexes 5. Motor Function 6. Sensory Function |
