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59 Cards in this Set
- Front
- Back
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Purpose of Physical examination
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To gather baseline data about the client's health; To supplement, confirm, or refute data obtained in the nursing history; To confirm and identify nursing diagnosis; To make clinical judgments about a client's changing health status and management; To evaluate the physiological outcomes of care
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Skills of Physical Assessment
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Inspection
Palpation Percussion Ausculation Olfaction |
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Inpsection
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is the process of observation
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Palpation
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is made through the sense of touch
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Light Palpation
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determines areas of tenderness
depressed about 1 cm (1/2 inch) |
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Deep Palpation
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is used to examine the condition of organs, such as those in the abdomen; depresses approx. 2 to 4 cm (1 to 2 inches)
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What is the most sensitive part of the hand?
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the palmar surface of the fingers and finger pads
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The radial pulse is detected with what?
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the pads of the fingertips
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What is measured the best using the dorsum or back of hand?
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Temperature
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The palm or ulnar surface of the hand is used for measuring what?
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vibration
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How do you test tugor?
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grasping the skin with the fingertips
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Percussion
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involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and to discover fluid in body cavities
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2 methods of percussion
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direct-involves striking the body surface directly with one or two fingers; indirect-is performed by placing the middle finger of the non-dominant hand firmly against the body surface, keeping the palm and remaining fingers off the skin
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Percussion produces five types of sounds
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tympany
resonance hyperresonance dullness flatness |
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Each sound is created by certain types of underlying tissues and is judged by
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1. its intensity of pitch
2. duration 3. quality |
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Ausculation
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is listening to sounds produced by the body
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Sounds can be heard while ausculating
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with the unassisted ear, although most sounds can be heard only through a stethoscope
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Important sounds to first learn
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normal sounds created by the cardiovascular, respiratory, and GI systems
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The nurse becomes more successful in auscultation by
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knowing the types of sounds arising from each body structure and the location in which they can most easily be heard
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To auscultate correctly
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the nurse need good hearing acuity, a good stethoscope, and knowledge of how to use the stethoscope properly
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Through auscultation the nurse notes the following characteristics of sounds:
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1. Frequency
2. Loudness 3. Quality 4. Duration |
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The first heart sound is caused by?
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the closure of the mitral valve
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The first heart sound is best auscultated at?
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the fifth intercostal space along the midclavicular line
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The first heart sound has the quality of?
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a loud "lub", whereas the second sound is a "dub".
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Olfaction
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the act of smell
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When examining children, the following tips assist in data collection:
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Get history from parents; Perform the exam in a non-threatening area and provide time for play to become acquainted; Offer support to the parents during the exam and do not pass judgment; Call children by their first name but address parents as "Mr. or Mrs".; Use open-ended question; Interview older children to allow observation of parent-child interaction; Treat adolescent as adult; Adolescents have the right to confidentiality
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Principles to follow during examination of an older adult include the following:
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Do not stereotype; Recognize that sensory or physical limitations can affect how quickly you are able to interview older adults and conduct exam; Perform the exam with adequate space; Use patience, allow for pauses and observe for details; Older clients may find giving certain types of health information stressful; Perform exam near bathroom facilities; Be alert to signs of increasing fatigue
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The following tips help the nurse keep an exam well organized:
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Compare both sides of the body for symmetry; If a client is seriously ill, first assess the systems of the body more at risk for being abnormal; If a client becomes fatigued, offer rest; Perform painful procedures near the end of the exam; Record in specific anatomical and scientific terms; Use common and accepted medical abbreviations; Record quick notes during exam to avoid keeping client waiting; A physical assessment form allows recording of information in the same sequence it is gathered
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General Appearance and behavior include the following:
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gender and race; age; signs of distress; body type; posture; gait; body movements; hygiene grooming; dress; body odor; affect and mood; speech; client abuse; substance abuse
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Macule
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flat, non-palpable change in skin color, smaller than 1 cm
EX: freckle, petechia |
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Papule
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palpable, circumscribed, solid elevation in skin, smaller than 0.5 cm
EX: elevated nevus |
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Nodule
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elevated solid mass, deeper and firmer than papule, 0.5 to 0.2 cm
EX: wart |
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Tumor
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solid mass that may extend deep through subcutaneous tissue larger than 1-2 cm
EX: epithelioma |
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Wheal
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irregular shaped, elevated area or superficial localized edema; varies in size
EX: hive, mosquito bite |
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Vesicle
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circumscribed elevation of skin (filled with serous fluid, smaller than 0.5 cm)
EX: herpes simplex, chicken pox |
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Pustule
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circumscribed elevation of skin similar to vesicle but filled with pus; varies in size
EX: acne, staphylococcal infection |
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Ulcer
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deep loss of skin surface that may extend to dermis and frequently bleeds and scars; varies in size
EX: venous stasis ulcer |
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Atrophy
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thinning of skin with loss of normal skin furrow, with skin appearing shiny and translucent; varies in size
EX: arterial insufficiency |
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Basal Cell Carcinoma
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0.5 to 1 cm crusted lesion that may be flat or raised and may have a rolled, somewhat scaly border
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Squamous Cell Carinoma
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occurs more often on mucosal surfaces and non-exposed areas of skin, compared with basal cell. 0.5 to 1.5 cm scaly lesion, may be ulcerated or crusted. Appears frequently and grows more rapidly than basal cell
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Melanoma
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0.5 to 1 cm brown, flat lesion that may arise on sun-exposed or non-exposed skin. Variegated pigmentation, irregular borders, and indistinct margins
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terminal hair
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long, coarse, thick hair easily visible on the scalp, axillae, pubic areas, and in the beard in men
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Vellus hair
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small, soft, tiny hairs covering the whole body except for the palms and soles
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hirsutism
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a woman with hair growth in the lip, chin, cheeks with vellus hair becoming coarser over the body
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cyanosis
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bluish-increased amount of deoxygenated hemoglobin; Causes: heart or lung disease, cold environment; Assessment location: Nail beds, lips, mouth, skin
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Pallor
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Decrease in color; Condition: Reduced amount of oxyhemoglobin Causes: anemia; Assessment locations: face, conjunctivae, nail beds, palms of hands
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Loss of pigmentation
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Causes: Congenital or autoimmune condition causing lack of pigment; Assessment location: Patchy areas of skin over face, hands and arms
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Jaundice
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Color: yellow-orange; Condition: Increased deposit of bilirubin in tissues; Causes: Liver disease, destruction of red blood cells; Assessment location: Sclera, mucous membrane, skin
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Erythema
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Color: Red; Condition: Increased visibility of oxyhemoglobin; Causes: Fever, direct trauma, blushing, alcohol intake; Assessment Locations: face, area of trauma, sacrum, shoulders, other common sites for pressure ulcers
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Tan-Brown
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Condition: Increased amount of melanin; Causes: suntan, pregnancy; Assessment locations: areas exposed to sun: face, arms, areolae, nipples
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Hair loss is usually related to?
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genetics tendencies and endocrine disorders
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The condition of the nails can reflect
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an individual's general state of health, state of nutrition, occupation, and level of self-care
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Inspection of nails
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inspects the nails beds for color, cleanliness, and length; the thickness and shape of the nail plate, the texture of the nail; the angle between the nail and the nail bed; and the condition of the lateral and proximal nail folds around the nail
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Palpation of nails
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the nurse gently grasps the client's finger and observes the color of the nail bed. Next gentle, firm, quick pressure is applied with the thumb to the nail bed and released. As the pressure is applied, the nail bed appears white or blanched; however, the pink color should return immediately on release of pressure
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Clubbing
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Change in angle between nail and nail base (eventually larger than 180 degrees); nail bed softening, with nail flattening; often enlargement of fingertips
Causes: chronic lack of oxygen; heart or pulmonary disease |
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Beau's lines
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Transverse depressions in nails indicating temporary disturbance of nail growth (nail grows out several months).
Causes: systemic illness such as severe infection; nail injury |
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Koilonychia (spoon nail)
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concave curves
Causes: iron deficiency anemia, syphilis, use of strong detergents |
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Splinter hemorrhages
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Red or brown linear streaks in nail bed
Causes: Minor trauma, subacute bacterial endocarditis, trichinosis |
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Paronychia
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inflammation of skin at base of nail
Causes: local infection, trauma |
