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110 Cards in this Set
- Front
- Back
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Subjective Data
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What pt. says
ie: I am in pain, it hurts here |
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Objective Data
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What you can observe about the pt. ie: Distress, pain,blood pressure, pulse
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General Survey includes:
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State of Client: Observed as you walk in
LOC Age: do they look their age? Nutritonal Status - obese, thin Personal hygiene Signs of distress Facial expression (pain scale) Mental Status: PP&O Height/weight Vital Signs |
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Vital signs to be included in a General Survey:
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Temp, pulse, resp, b/p, O2 saturation, pain
May include urinary status if they have a catheter |
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4 Techniques used in Assessments
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Initial - visual observation (use senses)
Palpation - touch (texture, temp) Percussion - with hands or instrument Auscultation - listening with stethoscope |
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Types of Assessment
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Initial
Focused Ongoing Emergency Comprehensive |
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Initial Assessment
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Vitals, history, what is your complaint?
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Focused Assessment
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Focus on reason for visit
Still includes vitals |
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Ongoing Assessment
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Get a baseline, then you can note changes over time
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Comprehensive Assessment
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ie: visiting Dr. for 1st time
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Types of Physical Exams
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Head to Toe
or System to system |
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Assessing Skin - what do you look for?
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pallor, cyanosis, flush, jaundice, lesions
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Assessing skin - Appearance of lesion or scar - what do you look for?
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size, shape, depth, border or wound or lesion/rash
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Assessing Hair - what do you look for?
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quality, distribution, color, texture
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Assessing Nails - what do you look for?
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color, shape (clubbing), capillary refill (more than 3 secs?)
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Where does Cyanosis show up besides the skin?
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Lips, gums, schlera of eye
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What is JVD?
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Jugular Vein Distention
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Cranial Nerve I
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Olfactory
smell |
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Cranial Nerve II
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Optic
vision |
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Cranial Nerve III
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Oculomotor
Extrinsic eye muscles, pupil dilation |
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Cranial Nerve IV
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Trochlear
Superior oblique eye muscles |
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Cranial Nerve V
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Trigeminal
Sensory for face, oral cavity corneal reflex |
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Cranial Nerve VI
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Abducens
Lateral Rectus Eye muscle |
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Cranial Nerve VII
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Facial
Taste, muscles of facial expression smile, frown |
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Cranial Nerve VIII
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Acoustic/Vestibulocochlear
Hearing |
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Cranial Nerve IX
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Glossopharyngeal
touch and taste on tongue swallowing |
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Cranial Nerve X
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Vagus
swallowing, |
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Cranial Nerve XI
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Accessory
Trapezius Muscle, Sternocleidomastoid muscle shrug, turn head |
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Cranial Nerve XII
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Hypoglossal
Tongue movement |
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erythema
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inflamed, red skin
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macule
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flat area, with discoloration
ie: mole, measles, freckles |
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Nodules
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elevated, marble like lesions
ie: on neck, vocal chords |
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papules
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small, rough, firm, raised bumps
ie: eczema |
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Plaques
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raised patches, in clusters, can vary in size. Don't go deep into skin layers
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vesicles
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Fluid filled blisters, usually clear fluid
ie: herpes zoster, chicken pox, poison ivy |
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Wheal
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Red, warm to touch, elevated, irregularly shaped, sometimes edema
ex: insect bite, hives |
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excoriation
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scraped, scratched looking
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Fissure
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cracks in the dermis
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Scales
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dry and flaky, thickened skin
psoriasis |
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Crust
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dried pus from broken vesicles
ex: impetigo |
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Ulcer
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deep erosions of the dermis, epidermis
pressure sores |
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striae
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stretch marks
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Skin Lesions - Linear
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in a line
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Skin Lesions - annular
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circular
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skin Lesions - Local
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in a particular area
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Skin Lesions - Generalized
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covering any/all areas
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Categories of Skin Color
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erythema
pallor jaundice cyanosis pink tone (normal) |
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Order of Assessment for Chest
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Inspect
palpate percuss ausculate |
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Angle of normal finger
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160 degrees
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Angle of clubbed finger
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180 degrees
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What does JVD indicate?
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cardiac issue (ie: congestive heart failure)
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What do clubbed fingers indicate?
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prolonged hypoxia
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At what angle should you place the pt for JVD inspection?
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30-45 degree angle
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Crepitus
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crackles under the skin
(ex can hear in the knee joint) |
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Percussion sounds of the thorax - Dullness
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percussing over something solid
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Percussion sounds of the thorax - Resonance
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percussing over something hollow
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Percussion sounds of the thorax - Tympony
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percussing over something empty
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Where do you place steth. for broncial sounds?
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over trachea
Inspiration is shorter that expiration |
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Where do you place steth. for Bronchovesicular sounds?
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over right and left bronchi
combo of sounds from the bronchi and the aveoli sound like blowing through a hollow tube Equal inspiration expiration |
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Where do you place steth. for vesicular breath sounds?
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In peripheral lung fields
Inpiration is longer that expiration High pitched during inpiration |
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Stridor
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airway obstruction
abnormal sound |
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Rhonchi
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crackles that clear with a cough
abnormal sound |
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Crackles
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fine or coarse, can't be cleared with a cough
abnormal sound |
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what part of the steth. should you use for heart murmurs?
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bell with light pressure
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What part of steth. should you use for high frequency sounds?
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Diaphragm
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What part of steth should you use for low frequency sounds?
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Bell
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What part of the steth should you use when examining the lungs and abdomen?
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diaphragm
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Where is the precordium located?
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overlies the heart and great vessels
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Where is the aortic area located?
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2nd intercostal, right side
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Where is the pulmonic area located?
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2nd intercostal, left of the sternum
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Where is the tricuspid area located?
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5th intercostal, left sternal border
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Where is the Erb's Point located?
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3rd intercostal space on the left sternal border (where murmurs can be heard best)
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Where is the Mitral area located?
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5th intercostal at the left midclavicular line
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What is PMI?
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Point of Maximal Impulse
Where the heart comes closest to the chest wall ( in Mitral area) |
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Name all of the peripheral pulses?
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temporal
carotid brachial radial ulnar femoral popliteal dorsalis pedia posterior tibialis |
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Name the anatomical divisions of the abdomen
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right upper quadrant
left upper right lower left lower |
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What is the order of assessment in the abdomen?
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Inspection
auscultation percussion palpation |
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what is rebound tenderness?
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tenderness once palpation is done
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parlytic ileus
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failure of peristalsis
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What is the most common post surgery complication?
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pneumonia
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What are the 6 f's?
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flatus
feces fat fluid fetus fatal growth |
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echymoses
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bruise
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when auscultating a quadrant of the abdomen, how many sounds should you hear in a minute?
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5-20
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How long should you auscultate each abdominal quadrant?
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up to 1 min 30 sec
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If you bowel sound are absent, how long should you auscultate before reporting?
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5 minutes
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what type of percussion do you use for the abdomen?
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indirect percussion
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how far can you palpate in the abdomen?
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1-2 inches deep
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What are the normal urinary output parameters?
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1 ml per kg per hour (usually 25 mls per hour)
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what is the normal daily urinary output in ml for a day
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700 - 1000 mls a day
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what are the most common tests for urinary function?
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BUN and creatinine
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what does BUN test for?
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hydration
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what does creatinine test for?
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renal function
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kyphosis
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hunchback
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scoliosis
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lateral curvature of the spine
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lordosis
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inward curvature of the spine
always in lower back also called swayback, saddleback |
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What are the types of muscle tone?
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normal
spastic flaccid |
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paresis
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impaired muscle strength
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hemiparesis
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impaird muscle strength on one side of the body
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what are the 6 main areas of neurological assessment?
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LOC
mental status cranial nerves motor function sensory function reflexes |
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describe decerebate posture
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wrist pronated, fingers flexed, feet plantar flexed
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describe decorticate posture
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feet turn in, hand/forearms are ridged across body (near the core)
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What is the Glasgow Coma Scale?
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A tool to assess the degree of pt.'s impaired conciousness
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What types of activity does the Glasgow Coma scale assess?
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Ability to open eyes
best verbal response best motor response 1-2 awake, 3-8 in coma |
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what does a pt's Mental Status refer to?
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orientation
Mood and affect speech and language memory cognition and judgement |
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what does orientation include?
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person, place and time
orientation to self is more impt that to others |
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What is affect?
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how a person expresses emotions, and are emotions appropriate for the situation
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what is flat affect?
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lack of emotional expression
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What is dysphonia?
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voice problem
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What is aphasia?
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impairment of language/inability to speak
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Where are the common reflexes located?
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Biceps, triceps, patellar, babinski (sole of foot)
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