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73 Cards in this Set
- Front
- Back
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KYPHOSIS
(posture) |
Shoulder and upper back curve forward.
hunchback |
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SCOLIOSIS
(posture) |
Curvature of a portion of the spine to the side laterally.
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LORDOSIS
(posturea) |
Commonly known as "swayback" in which
the lumbar region curves inward and the sacral region curves outward. |
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Abnormal Gait
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Slow, measured steps, limping, leaning to one side, shuffling the feet, shorter steps, wide outward swinging of 1 legm wide gait, leaning trunk forward, lifting the knee higher than normal, short hurrying steps
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4 Techniques of
PHYSICAL EXAMINATION |
* Inspection
* Palpation * Percussion *Ausculation |
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INSPECTION
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Used to make specific observations of physical features & behavior.
Obtain vital signs, height, and weight measurements. |
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GENERAL SURVEY
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Apparent state of health, level of consciousness, and signs of distress.
Height, weight, build, skin color, dress, grooming, personal hygiene, facial experession, odors, posture, gait, motor activity. |
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PALPATION
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Usually follows Inspection
Use of hands & fingers to gather information through touch. Used to discriminate position, texture, size, consistency, masses, and fluid Light palpation - 0.5" to 1" - detect discomfort or abnormal masses Deep - 1.5" to 2" - locate organs, check size, detect abnormal masses |
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PERCUSSION
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Uses the sense of hearing, involves using fingers & hands to tap an area on the client to produce sound.
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RESONANCE
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Degree to which sound propagates.
Air-filled spaces are resonant while solid tissue is not. |
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5 Characteristic tones that
PERCUSSION produces |
1. Tympanic - abdomen
2. Hyperresonant - hyperinflated lung 3. Resonant - normal lung tissue 4. Dull - liver 5. Flat - bone |
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CORE TEMPERATURE
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Range between 36.5 to 37.5 Celsius
97.6 to 99.6 F |
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AUSCULTATION
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Listening for sounds of movement within the body.
Heart & blood - moving blood Lung - moving air Abdomen - moving gastrointestinal contents If a client has body hair over the area of auscultation, wetting it with water reduces the crackling sound that hair creates. |
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DIAPHGRAM
of a Stethoscope |
detects HIGH-pitched sounds.
ex. breath, heart & bowel |
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BELL
of a Stethoscope |
detects LOW-pitched sounds.
ex. abnormal heart sounds, bruits |
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4 Properties to describe Sound
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* Frequency - meaure of vibrations, cycles per second
* Intensity - loudness of breath * Duration - length of sound * Quality - musical characteristics of a sound. |
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RECEPTIVE APHASIA
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Unable to understand simple directions.
Problem receiving communication. |
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EXPRESSIVE APHASIA
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Understands and follows directions but unable to communicate verbally.
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ACCOMODATION
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Tested by having the client look at a close object and
then look at a distant object. |
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OTOSCOPE
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Instrument examining the ear, visualize the canal.
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BRUITS
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Occur when an artery is partially obstructed or distended,
which prevents blood flow from moving straight through the vessel. |
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PALLOR
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Skin color may also appear pale with hypoxia & anemia.
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JAUNDICE
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Yellow tone to the skin and is observed in liver disease.
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ERYTHEMA
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Redness, usually from irration or inflammation.
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SKIN TURGOR
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Amount of fluid in the tissues.
If skin turgor is poor, skin remains elevated or slowly resumes position. Indicate dehydration or normal aging or weight loss. |
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CLUBBING
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of the nail is a sign of chronic hypoxia.
Nail becomes less adherent to the base of the nail & feels spongy, appears "drumstick-like". |
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MURMUR
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Vibrating sound that results from turbulent blood flow through the heart, esp across the valves.
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A comprehensive health assessment encompasses:
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the physical, psychological, social, and spiritual dimensions of living - should take approx 45 min
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Focused Health Assessment
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based on the client's problems.
Components of a focused assessment include performing a general survey, taking vital signs, and assessing specific areas that relate to the problem. |
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The 3 major frameworks for organizing assessment data are:
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the functional health framework, the head-to-toe framework,
and the body systems framework. - Developing a consistent, comprehensive method for assessment is more important than which specific framework a nurse decides to use. |
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Functional Health Assessment
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Evaluates the effects of the mind, body, and environment in relation to a person's ability to perform the tasks of daily living.
- Often, nurses collect subjective information using functional health patterns but conduct the physical assessment using a head-to-toe approach |
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Head-to-Toe Framework:
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is a system for collecting data in an organized manner, starting from the head and proceeding systematically downward to the toes.
Used to improve efficiency and to expedite the actual physical examination. |
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Body systems framework
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physicians and advanced nurse practitioners commonly use.
It focuses on the pathophysiology involved within specific body systems (e.g., cardiovascular, genitourinary). A body systems approach may be used during the focused assessment of an acutely or critically ill client to determine function of a particular body system |
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Conducting a Health Assessment
- Considering Culture |
Often, the client's language, customs, beliefs, and values differ from those of the nurse performing the assessment. A nurse's conscious or unconscious biases can influence his or her interpretation of data
- When using an interpreter, speak to the client and use language as if you were speaking directly to the client - some people regard direct questioning as invasive and are more receptive to a warmer and more casual type of interview. In some cultures, the husband is the family spokesperson and must be present during the health assessment of his wife and children. Knowledge and awareness of these differences among cultures can help prevent inadvertent miscommunication. |
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Preparing the client's environment
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Pull the curtains around the bedside, and position yourself so you are facing the client
- Ask the client if he or she needs to use the bathroom before beginning the assessment, especially if you anticipate an abdominal assessment - The assessment and treatment of the problem takes priority when a client is uncomfortable or acutely ill. |
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Organizing and Documenting Data
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Document pertinent information (e.g., quotations, abnormal values) during the interview, and complete the remainder of the form after the conclusion.
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Obtaining Subjective Data: the Interview
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The nurse who sits at eye level with the client, appears unhurried and alert, and takes notes conveys to the client that the information being shared is important and deserves attention.
- use open or closed-ended questions as needed - Many clients have difficulty staying on a topic or limiting their answers to significant points. A sensitive yet effective method for directing the client might be “Because our time is limited, we won't be able to discuss that in detail now. I would like to hear more about…” |
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Reason for Seeking Healthcare
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Listen carefully to the client's description of the primary problem and document it, when possible, quoting the client's exact words. In-depth questioning and discussion of this problem should follow.
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Pain Assessment
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Addressing pain early in the health assessment allows the nurse to individualize the rest of the assessment, avoiding positioning and techniques that are especially uncomfortable for the client. If the client is in severe pain, lengthy questioning is best postponed. Acknowledging the client's pain and verbalizing your efforts to limit discomfort during the assessment are important.
- Acute illness, chronic disability, surgical intervention, and treatment modalities can all cause the client pain. - Pain can limit normal function and affect wellness and quality of life |
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Pain Assessment should include
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asking the client to describe the location, intensity, quality,
onset, and chronology of his or her pain experience. |
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Questions helpful in soliciting subjective information concerning the client's pain experience include the following:
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* Do you have any pain or discomfort? How long have you had it?
* If yes, tell me how bad it is on a 0 to 10 scale, with 10 being the worst. * Show me where it is. Does it move or radiate anywhere? * Describe what it feels like. * When does it come on? How long does it last? *What makes it better? What makes it worse? |
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Acute pain stimulates the sympathetic nervous system and
produces the following objective symptoms: |
increased blood pressure, increased pulse,
increased respiratory rate, dilated pupils, and diaphoresis - This sympathetic response is not present in chronic pain states, and these parameters may be absent if pain has been present for several weeks. |
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Discuss the client's health-promotion activities, allergy history, health perception & health maintainence
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exercise, nutrition, routine preventive examinations (e.g., dental, vision, hearing), immunization history, safety precautions (e.g., child safety seats, bicycle helmets), and stress management
- allergies to medication, food, pollen, insect, latex and any environmental allergens -knowledge, behavior, and attitudes toward preventing disease and living a healthy lifestyle |
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Gait and Balance
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Gait describes a person's manner of walking.
Balance refers to stability and equality between both sides of the body. |
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Decreased Mobility
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when a client's mobility or self-care functions are compromised,
a daily living assessment should be performed |
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Assessment of Nutrition and Metabolism
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The nutrition–metabolism assessment should focus on normal food and fluid intake, alterations in normal eating patterns, how dietary changes have affected daily living, and the development of medical problems secondary to altered nutritional status.
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Self -Care Abilities Scale
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0—Full self-care, independent
I—Needs to use equipment or device II—Needs supervision III—Needs equipment or device and supervision IV—Unable to perform, dependent |
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Formula to calculate the percentage of weight change:
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(Current weight - Usual weight)/Usual weight = Percentage of weight change
In general, a change in weight of 10% during the last 6 months is considered to be abnormal (Jarvis, 2004). A dietitian should be consulted for further evaluation. - Rapid weight gain or loss (e.g., 10 lb in 2 weeks) usually results from the gain or loss of body fluid, rather than body fat. |
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Assessment of Elimination
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focuses on determining the adequacy of bladder and bowel function, identifying risk factors that may contribute to problems in elimination, assessing the impact of bladder or bowel dysfunction on daily living, and understanding the client's methods of managing and coping with any dysfunction.
Focus on the client's normal urinary and bowel patterns, noting any recent changes. |
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Assessment of Sleep and Rest
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focuses on the client's normal sleep patterns, alterations from the normal pattern, and satisfaction with quality of rest and sleep.
Sleep habits, problems with obtaining adequate rest or sleep, and any aids that the client uses to induce sleep are important areas to consider. |
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Assessment of Cognition and Perception
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Factors that contribute to cognition include awareness, thought processes, memory, language, judgment, and attention span. Whereas significant impairment in cognitive abilities is readily noticeable on the first interaction, repeated assessments over time are often required to detect subtle changes or minor deficits in cognitive ability.
- Assessment should also include the impact sensory deficits have on activities of daily living (ADLs) and any devices the client uses to cope with sensory impairment. - During the interview, observe the client for signs of sensory impairment, such as asking questions to be repeated, watching lips closely during speech, squinting to improve vision, or holding reading material at arm's length. |
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Assessment of Self-Perception and Self-Concept
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The components of self-concept include one's self-knowledge, self-expectation, social self, and self-evaluation. The ways in which others evaluate and interact with a person throughout the lifespan influence self-concept. Body image, the mental picture and feelings about one's body, is an important component of self-concept. Individual beliefs concerning locus of control are also important to explore. Some people believe that life events are self-determined (internal locus of control), whereas others view individual happenings as a matter of fate, luck, or the influence of others (external locus of control).
- Collect subjective and supporting objective data concerning normal self-concept, recent changes in self-concept, and the presence of conditions (e.g., burns, skin disorders, colostomy, mastectomy, obesity) that could threaten or alter body image. - Eye contact, personal grooming and appearance, posture, body movements, mood, emotions, and voice and speech pattern are nonverbal cues to a client's self-concept. |
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The goal in a basic health assessment is:
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to identify the client's major roles in the family, at work, and in social life and to identify the client's relative satisfaction or dissatisfaction with each role.
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Within the family unit, important information includes:
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who shares the household, what responsibilities or dependencies each member has, and the presence of specific problems, such as issues related to parenting, caring for elderly parents, or marital discord.
- A change in relationships may contribute to the cause or exacerbation of an illness |
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Safety Note
Assessment of Roles and Relationships |
Note repeated unexplained injuries, such as bruises, burns, or fractures, as a possible sign of abusive relationships. Frequently, people involved in abusive relationships verbally deny that abuse has occurred.
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Assessment of Coping and Stress Tolerance
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Although stress is most readily conceptualized as negative, positive life changes also challenge a person and therefore create stress
- The way in which a person reacts and, it is hoped, adapts to stress is called a coping behavior. |
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Stress activates the Sympathetic Nervous System
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producing certain physiologic effects. Sympathetic stimulation may increase the force and rate of the heartbeat; increase respiratory rate and depth; decrease blood flow to the skin, resulting in pallor and diaphoresis; and increase blood flow to the muscles. These symptoms may be pronounced in the event of a sudden stressful event. When a person is exposed to chronic stress, the symptoms may be less sudden and less dramatic.
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Assessment of Sexuality and Reproduction
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Physical illness and its treatment may influence sexual function
- The areas for assessment of sexuality and reproduction include reproductive functioning, sexual role and satisfaction with that role, and potential for alteration in sexual role or function *Many men (or women) in your situation have questions about how their illness or surgery will affect the sexual aspects of their lives. What questions do you have? |
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Assessment of Values and Beliefs
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Values help determine choices about the conduct of one's life, including health-related decisions concerning personal practices, treatments, and even life or death
- Because body, mind, and spirit are intertwined, distress in any one area affects the health of the whole person. - A nurse who understands a client's spiritual beliefs is better prepared to support coping strategies and provide resources that are spiritually helpful to the client. |
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Physical examination
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involves the use of one's senses to obtain information about the structure and function of an area being observed or manipulated.
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Positioning and Draping
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Draping is a method to help ensure privacy. During the examination, cover the client's body parts that are not included in the specific examination taking place, exposing only the part of the body being examined.
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General Inspection of a client focuses on the following areas:
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* Overall appearance of health or illness: Does the client appear weak, frail, or older than the stated age?
* Signs of distress: Is the client grimacing, as if in pain? Is breathing labored? Is the skin blue or pale? * Facial expression and mood: Does the client appear anxious, depressed, angry, or uninterested? * Body size: Does the client appear thin and malnourished or overweight? *Grooming and personal hygiene: Are the client and his or her clothing clean and neat? Is there an unusual odor? |
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Tangential lighting
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is provided by indirectly shining light with a lamp or flashlight to create a shadow over the examined area. The shadow brings out subtle differences in contour and movement.
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Palpation - Diff parts of hand for diff uses
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The fingertips are concentrated with nerve endings and can sense fine differences in texture and consistency. They are used to discriminate raised versus flat skin lesions or to evaluate an arterial pulse. The skin over the dorsum of the hand is sensitive to temperature because it is thin and its nerve density is great. Skin temperature over a specific area may be evaluated by comparing its temperature with that of adjacent areas or the opposite side of the body. The palm of the hand is sensitive to vibration and is useful in locating a vibration associated with a heart murmur.
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2 Types of Percussion
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Direct percussion is accomplished by tapping an area directly with the fingertip of the middle finger or thumb. Indirect percussion interposes a finger between the area to be percussed and the finger creating the vibrations; indirect percussion usually is used
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Stethoscope
Diaphragm VS Bell |
The diaphragm is a flat piece that is applied firmly against the skin and responds best to high-frequency sounds. The bell is a funnel- or cup-shaped head that collects low-pitched sounds. The bell should simply be allowed to rest on top of the skin; if too much pressure is applied, the skin is stretched and a diaphragm effect is produced.
- The stethoscope collects and transmits sound, selects frequencies, and screens out extraneous sound. Although sound transmitted through the stethoscope seems loud, the stethoscope does not amplify the sound |
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Level of Consciousness
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At the highest level of consciousness, a person responds to environmental stimuli with appropriate verbal and motor activity.
- Nurses are able to detect subtle changes in a client's consciousness state by reviewing the Glasgow Coma scale and noticing deviations from baseline. |
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Glasgow Coma Scale
Best Eye-Opening Response |
4 - Purposeful and Spontaneous
3 - to Voice 2 - to Pain 1 - No response U - Untestable |
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Glasgow Coma Scale
Best Verbal Response |
5 - Oriented
4 - Disoriented 3 - Inappropriate Words 2 - Incomprehensible Sounds 1 - No Response U - Untestable |
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Glasgow Coma Scale
Best Motor Response |
6 - Obeys Commands
5 - Localizes Pain 4 - Withdraws to Pain 3 - Flexion to Pain 2 - Extension to Pain 1 - No Response U - Untestable |
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Orientation
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ask simple, direct questions about time, place and person
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Mood
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Normal
Euphoric Depressed Irritable - Those with a rapid change of emotions may be described as labile. A client whose affect is clearly out of context with the situation may be described as having an inappropriate affect. Flat affect describes the client who expresses few emotions. |
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Dysarthria
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Mechanical, muscular, or sensory problems may cause difficulties with articulation of words
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