Physical Assessment Pt. 2 0F 2 (Basics In Nursing)

Front 1

(def)

an abnormal accumulation of fluid in the interstitial spaces of tissues

Back 1

edema

Front 2

Edema is always _________.

Back 2

abnormal

Front 3

Edema may be caused how?

Back 3

- damage to an area of the body and the inflammatory response
- low albumin in the blood can cause plasma to seep into interstitial spaces
- any problem with a body system that regulates fluid (ex. cardiac, renal)
- impairment of venous return which overrides the capacity of the veins (ex. pregnancy)
- malnutrition

Front 4

What is more likely to happen to edemic skin? What implication does this have on the nurse?

Back 4

Skin is more likely to tear/breakdown; you must immediately start care to protect the skin

Front 5

A client is suffering from edema in her feet. You push on the skin and it leaves an indentation. What is this referred to as?

Back 5

pitting edema

Front 6

True/False:

Pitting Edema is more severe than edema that does not pit.

Back 6

False- This does not indicate severity of the edema. However, the nurse must document whether the area afflicted with edema pits or not.

Front 7

If edema forms around the eyes, it is called what?

Back 7

periorbital edema

Front 8

If edema is located in the brain, it is called what?

Back 8

cerebral edema

Front 9

Edema in the pericardial sac is called what?

Back 9

pericardial effusion

Front 10

Edema in the intrapleural space is called what?

Back 10

pleural effusion

Front 11

Edema in the abdominal cavity is called what?

Back 11

ascites

Front 12

Generalized Edema (all over) is called what?

Back 12

anasarca

Front 13

Edema is affected by gravity and therefore is commonly seen in what areas?

Back 13

Dependent areas

Front 14

What dependent area in an active person would likely be affected by edema? How about a client on bedrest?

Back 14

Active persons would likely suffer in feet and legs.

Bedrest persons would likely suffer in the sacral/dorsal regions of the body.

Front 15

A client is being treated for liver disease. You suspect ascites. What method would you use to assess this client for changes?

Back 15

abdominal girth measurements (done at the umbilical level) AND daily weight measurements

Front 16

A nurse is caring for a client with ascites as a secondary symptom. She writes an independent order - Semi-Fowler's Position or higher at all times. Why do you think she wrote this order?

Back 16

to reduce pressure on the diaphragm and ease breathing

Front 17

(def)

any abnormal area of the skin (wound, cyst, rash, boil, pustule, tumor, etc.)

Back 17

lesion

Front 18

(def)

an injury to a surface of the body caused by trauma, such as scratching, abrasion, or a chemical or thermal burn.

Back 18

excoriation

Front 19

What is the procedure for assessing lesions of the skin?

Back 19

- assess for location, size, shape, color, texture, raised or flat, mobility, drainage, tenderness, etc.

Front 20

What guidelines do we use when reporting lesions? Briefly describe each guideline.

Back 20

American Dermatology Association Guidelines

Report: A, B, C, & D

A= Asymmetry
B= Border Irregularity
C= Change in color or elevation
D= diameter >6mm

Front 21

True/False:

You should call the doctor immediately if you find an abnormal skin lesion.

Back 21

False - document and let the doctor know during his next shift.

Front 22

What are some normal skin lesions that may be seen in an older adult?

Back 22

- skin tags
- senile keratosis (thickening)
- cherry angiomas
- atrophic warts

Front 23

True/False:

When examining hair, you should focus solely on the hair found on the head.

Back 23

False- You should examine all hair (eyebrows, underarm, pubic, etc.)

Front 24

What determines the color of your hair?

Back 24

melanin

Front 25

Describe the normal attributes of hair.

Back 25

- straight/curly
- fine/course
- shiny and resilient
- should not come out in clumps >5 strands when gently tugged

Front 26

Normal male or female pattern of baldness is _________.

Back 26

hereditary

Front 27

On average, how many strands of hair do you lose per day?

Back 27

100

Front 28

Hair is a good indicator of nutritional health, especially the body's _______ status.

Back 28

protein

Front 29

(def)

a partial or complete lack of hair resulting from normal aging, an endocrine disorder, a drug reaction, an anticancer medication, or a skin disease.

Back 29

alopecia

Front 30

Describe abnormal attributes for hair.

Back 30

- brittle
- listless
- dull
- above normal hair loss

Front 31

What are some causes of abnormal hair loss?

Back 31

- serious infections
- chronic illness
- loss of hair on lower extremities may be caused by poor perfusion

Front 32

What are normal attributes for hair in the elderly?

Back 32

- thinning
- graying
- decreased in legs, axillae, pubic areas
- hormonal shifts may cause more hair on ears, eyebrows of males and face of females

Front 33

What is the procedure for inspecting the head/scalp of an adult?

Back 33

inspect skull for shape and size, palpate for lesions using a rotating motion with the fingertips

Front 34

What is the procedure for inspecting hair?

Back 34

- inspect for even distribution, thickness
- palpate for texture, oiliness
- check for infestations
- gently tug on hair for hair loss
- observe hair over entire body

Front 35

Describe the normal skull and scalp.

Back 35

- normocephalic
- symmetrical
- scalp = shiny, intact, no lesions

Front 36

(def)

a pathologic condition characterized by an abnormal accumulation of CSF within the cranial vault and subsequent dilation of the ventricles

Back 36

hydrocephalus

Front 37

(def)

abnormal growth of the hands, feet, and face, caused by overproduction of growth hormone by the pituitary gland.

Back 37

acromegaly

Front 38

Describe abnormal features you should look for when inspecting head/scalp.

Back 38

- hydrocephalus
- acromegaly
- scalp lacerations, lesions, indications of trauma

Front 39

What nursing implications must you consider in relation to the head/scalp region?

Back 39

- shearing force
- prolonged pressure is client is on bed rest

Front 40

What is the procedure for inspecting the face?

Back 40

- inspect facial features for symmetry.
- ask client to raise eyebrows, puff cheeks, smile

Front 41

Describe normal findings when inspecting the face.

Back 41

- symmetrical features
- tops of ears should align with the outer canthus of the eyes
- nose is midline

Front 42

Describe abnormal findings you should look for when examining the face.

Back 42

- facial drooping
- asymmetry
- (specific disorder cues such as CVA, Bells Palsy, Parkinson's)

Front 43

A defect in CN VII may be indicative of what 2 disorders?

Back 43

- Bells Palsy
- CVA

Front 44

A blank stare with little expression combined with raised eyebrows may indicate what disorder?

Back 44

Parkinson's

Front 45

What should you specifically check when examining a patient's eyes?

Back 45

- visual acuity
- eyelids
- sclera
- conjunctiva
- cornea/lens
- pupils

Front 46

What cranial nerve is responsible for sight?

Back 46

CN II (Optic Nerve)

Front 47

(def)

the ability to see

Back 47

visual acuity

Front 48

What is the procedure for checking visual acuity?

Back 48

- hold 2 or 3 fingers up (about a foot away) and ask client to identify
- identify a common object (ex. a pen, a watch)

Front 49

Describe normal visual acuity.

Back 49

able to identify common object at 1-20 feet

Front 50

What abnormalities may you find when testing visual acuity?

Back 50

- myopia
- hyperopia

Front 51

(def)

nearsightedness

Back 51

myopia

Front 52

(def)

farsightedness

Back 52

hyperopia

Front 53

What are some changes in visual acuity you may see in older adults.

Back 53

- reduced adaptation to darkness
- sensitivity to glare
- presbyopia

Front 54

(def)

farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age.

Back 54

presbyopia

Front 55

At what age does presbyopia typically begin?

Back 55

middle age >45

Front 56

What is the procedure for examining eyelids?

Back 56

- observe position of upper lids in relation to upper borders of the iris
- notice frequency of blinking

Front 57

Describe normal eyelids.

Back 57

- symmetrical
- upper lids cover upper portion of the iris
- when closed, lids cover cornea

Front 58

(def)

drooping of the eyelid

Back 58

ptosis

Front 59

What nerve controls the eyelid muscles?

Back 59

CN III (oculomotor)

Front 60

Ptosis may be indicative of what 3 serious neurological disorders?

Back 60

- CVA
- MS
- MG (myasthenia gravis)

Front 61

What changes may you notice in the older adult when examining eyelids?

Back 61

mild bilateral ptosis from loss of skin elasticity

Front 62

What CN controls the pupil?

Back 62

CN III (oculomotor)

Front 63

What terms should be used to indicate a specific area within the eye? (ex. a scratch, red area)

Back 63

nasal/temporal

Front 64

You should inspect the pupils for what 4 things?

Back 64

color, symmetry, size and shape

Front 65

What is the procedure for examining the sclera?

Back 65

- ask client to look up, down, side to side
- nurse may open lids if client is unable to do so

Front 66

Describe normal sclera.

Back 66

- moist
- light skin clients = color is off white
- dark skin clients = color is tan with brown areas of melanin

Front 67

What abnormalities might you find when examining the sclera?

Back 67

- uniformly yellow (jaundice)
- bluish (thinning of skin/hypoxia)

Front 68

What is the normal procedure for examining the conjunctiva?

Back 68

- retract lower lid with nurse's opposite thumb; inspect as client is asked to look upward

Front 69

Describe the normal conjunctiva.

Back 69

Pink, moist with some small blood vessels visable

Front 70

Describe abnormal conjunctiva.

Back 70

- pale (anemia)
- conjunctivitis (reddened with or without purulent discharge)

Front 71

(def)

an opaque ring, gray to white in color, that surrounds the periphery of the cornea; caused by lipid deposits; harmless. Occurs primarily in older adults.

Back 71

arcus senilis

Front 72

Describe normal cornea/lens.

Back 72

Moist, shiny without discharge, cloudiness or irregularities

Front 73

Describe abnormal cornea/lens.

Back 73

Ulcers
Dryness
Lacerations (from trauma or contact lenses)

Front 74

Describe normal findings when examining pupils.

Back 74

- PERRLA (pupils equal, round, react to light and accommodation)
- Size 2-7 mm
- brisk response to light
- bilateral direct and consensual responses
- mydriasis
- miosis

Front 75

(def)

dilation of the pupil for distance

Back 75

mydriasis

Front 76

(def)

pinpoint constriction of the pupil for close sight

Back 76

miosis

Front 77

Describe abnormalities you may see when observing pupils.

Back 77

- pinpoint or dilated pupils

Front 78

Pinpoint sized pupils may indicate what?

Back 78

- narcotic opioid use
- some glaucoma medications

Front 79

Dilated pupils may indicate what?

Back 79

- sympathetic stimulation
- blocking of parasympthetic system to dry oral secretions (ex. the drug Atropine)
- Increased Intracrainal pressure

Front 80

If a client's eyes are dilated, what is your next step in the examination?

Back 80

Ask the client if they have had surgery (ex. cataract or glaucoma surgery)

Front 81

(def)

contraction of the pupil of one eye when the other retina is stimulated; it is a normal reflex and a test to evaluate the second and third cranial nerves

Back 81

consensual response (reaction)

Front 82

(def)

an adjustment of the eyes for near vision, consisting of pupillary constriction, convergence of the eyes, and increased convexity of the lens

Back 82

accommodation reflex

Front 83

Describe the test used for accommodation reflex.

Back 83

Hold a pen/finger directly in front of client. Ask them to focus on it, followed by focusing on the wall behind the object.

Front 84

What do you write on the chart if the client passes all pupil examinations?

Back 84

PERRLA

Front 85

Describe the normal test for inspecting the ear.

Back 85

- inspect for position of the ear (superior border at the level of the canthus)
- lift pinna upward to open ear canal, inspect for cerumen/drainage
- occlude one ear and whisper a "simple" word into client's other ear. Ask them to repeat it.

Front 86

Describe normal ear findings.

Back 86

- intact if hears whispered word
- yellow/brown cerumen in external ear canals

Front 87

Describe abnormal ear findings.

Back 87

- presbycusis
- clear watery drainage could be CSF (report STAT)

Front 88

(Def)

hearing deficit

Back 88

Presbycusis

Front 89

Green or Gold cerumen may indicate what?

Back 89

infection

Front 90

What does the abbreviation HOH mean?

Back 90

Hard of Hearing

Front 91

Describe the normal procedure for inspecting the nose.

Back 91

- inspect position
- lift tip and inspect for moisture, drainage, equality of airflow

Front 92

Describe normal findings for the nose.

Back 92

- midline
- nares patent, without discharge
- mucosa pink, moist

Front 93

Describe abnormal findings of the nose.

Back 93

- deviated septum (can obstruct airflow)
- edema
- excoriation (injury to the body)

Front 94

What changes can you expect to not in the older adult regarding the nose?

Back 94

- decreased sense of smell

Front 95

What structures do you examine when looking at the mouth?

Back 95

- lips
- mucus membranes
- tongue
- uvula
- gums
- teeth

Front 96

Describe the procedure for inspecting the mouth.

Back 96

- inspect lips for symmetry, color, moisture.
- ask client to protrude the tongue and move it left and right.
- using a penlight and tongue blade, inspect all mm (tongue, hard palate, buccal mucosa, structures of the oropharynx in sweeping order, inspect teeth

Front 97

Describe normal findings when inspecting the mouth.

Back 97

- oral mucosa pink and moist
- tongue and uvula midline
- 32 teeth
- dark skinned clients may have brown patches of melanin on mm

Front 98

(def)

no teeth

Back 98

Edentulous

Front 99

(def)

cavities

Back 99

caries

Front 100

What abnormalities might you find when inspecting the mouth?

Back 100

- pallor
- cyanois
- dry
- tongue deviates left or right
- Candidiasis or thrush
- Endentulous
- Caries
- Gingival hyperplasia

Front 101

(def)

white coating on the tongue

Back 101

Candidiasis (thrush)

Front 102

(def)

large, red gums

Back 102

Gingival hyperplasia

Front 103

What effect might you see on the gums of a client who is taking Dilantin - an anticonvulsant medication?

Back 103

Gingival hyperplasia

Front 104

What changes might you see in the mouth of the elderly?

Back 104

- decreased sense of taste
- dry mm
- may have lost teeth

Front 105

Describe the procedure for examining the neck.

Back 105

- Visually inspect for symmetry, position of head and trachea.
- Apply resistance- ask client to move head left, right, up and down.
- Ask client to touch ear to shoulder
- Palpate trachea
- Ask client to tilt head to one side and palpate carotid pulse for rhythm and volume (avoid excessive pressure) - Repeat on other side and mentally compare

Front 106

Describe normal findings when examining the neck.

Back 106

- FROM (full range of motion)
- trachea midline
- carotid pulses equal, regular, strong

Front 107

Describe abnormalities you may find when examining the neck.

Back 107

- Limited ROM
- Trachea deviated
- Carotid pulses unequal, weak, irreg.

Front 108

What might a deviated trachea indicate?

Back 108

collapsed lung

Front 109

What changes might you see in the elderly when examining the neck?

Back 109

- sagging of skin
- weakened neck muscles
- limited ROM

Front 110

Describe the procedure for examining breasts.

Back 110

- inspect for symmetry, discharge, and dimples. Ask about pain.

Front 111

True/False:

You can bypass the breast examination in male clients.

Back 111

FALSE- breast cancer is found in male clients as well as female clients. You should NEVER bypass this part of the physical.

Front 112

Describe normal findings for breasts.

Back 112

symmetrical; without dimpling or discharge; non-tender

Front 113

Describe abnormal findings for breasts.

Back 113

asymmetrical; dimpling or discharge; palpable mass

Front 114

Describe the procedure for examining the ANTERIOR thorax.

Back 114

- Inspect for symmetry of the clavicles/ribs.
- Observe breathing pattern, rate, rhythm.
- Observe effort used to breath (note if accessory muscles are used)
- Observe is excursion/expansion of both sides of the thorax is equal
- Inspect for intercostal retractions or bulging

Front 115

What is the normal ratio of transverse diameter to anterior-posterior diameter of the thorax?

Back 115

2:1

Front 116

What term is used to describe a thorax where the transverse diameter and anterior-posterior diameter is equal or the ant-post is greater than the transverse?

Back 116

barrel chest

Front 117

What is the cause of Barrel Chest?

Back 117

air-trapping (as seen in COPD)

Front 118

Describe the procedure for examining the posterior thorax?

Back 118

- inspect for symmetry
- inspect for spinal alignment (straigtness)
- inspect for equality of excursion
- inspect skin integrity
- check for sacral edema

Front 119

Describe normal findings for the thorax.

Back 119

- symmetrical clavicles/ribs
- costal angle equal to or greater than 90 degrees
- Equal expansion (anterior and posterior)
- Eupnea
- Transverse greater than AP diameter
- spine midline/straight
- skin intact with no redness or edema

Front 120

Describe abnormal findings for the thorax.

Back 120

- asymmetrical
- unequal expansion
- paradoxical movement
- use of accessory muscles to breath
- labored breath
- intercostal retractions or bluging
- Barrel Chest

Front 121

What might you expect to see when examining the thorax of an older adult?

Back 121

- muscle atrophy and chest rigidity
- barreling due to decreased expansion

Front 122

What are you analyzing when you examine lung sounds?

Back 122

- equality (from side to side)
- characteristics of the lung sounds

Front 123

The size of the airway determines the lung sounds. Therefore, the larger the airway diameter, the _______ and ________ the sound should be.

Back 123

louder and harsher

Front 124

What 3 breath sounds do we examine?

Back 124

- Bronchial (tubular)
- Bronchovesicular
- Vesicular (Periphery)

Front 125

Which side of the stethoscope do you use to analyze lung sounds?

Back 125

diaphragm

Front 126

How long should you analyze each lung sound?

Back 126

at least one full cycle at each location

Front 127

Describe the procedure for analyzing anterior lung sounds.

Back 127

- Auscultate Bronchial
- Next auscultate bronchovesicular
- Next auscultate the vesicular

*Ask client to take deep, slow breaths*

Front 128

Describe in detail the procedure for evaluating bronchial sounds anteriorly.

Back 128

Assess left an right region over the trachea

Front 129

Describe in detail the procedure for evaluating bronchovesicular breath sounds anteriorly.

Back 129

- Listen at the sternal borders between 1-2 ICS

Front 130

Describe in detail the procedure for evaluating (periphery) vesicular breath sounds anteriorly.

Back 130

- Listen at supraclavicular spaces (apex)
- Listen to the mid-fields (midclavicular, anterior axillary, and mid-axillary lines
- Listen to the bases (midclavicular, anterior axillary, and mid-axillary lines)

Front 131

Describe in detail the procedure for examining bronchovesicular breath sounds posteriorly.

Back 131

- listen between the scapulae

Front 132

Describe in detail the procedure for examining the periphery (vesicular) breath sounds posteriorly.

Back 132

- listen at suprascapular areas
- listen to mid-field at the mid-scapular and posterior axillary lines
- listen to bases at the mid-scapular and posterior axillary lines

Front 133

Describe normal findings for bronchial (tubular) sounds.

Back 133

- harsh, loud
- Inspiration should be shorter than expiration

Front 134

Describe normal findings for bronchovesicular sounds.

Back 134

- inspiration equal to expiration

Front 135

Describe normal findings for vesicular (peripheral) sounds.

Back 135

- inspiration should be greater than expiration
- very quiet

Front 136

What are some abnormal findings regarding breath sounds.

Back 136

- unequal sounds
- adventitious sounds
- crackles
- wheezes
- rhonchi
- stridor

Front 137

(def)

the incorrect sound is heard in a location

Back 137

adventitious sounds

Front 138

(def)

partial or complete collapse of a lung

Back 138

atelectasis

Front 139

What lung sound may be heard when atelectasis or fluid in the alveoli sacs is present?

Back 139

crackle

Front 140

What lung sound may be produced due to narrowed bronchial airways.

Back 140

Wheezes

Front 141

What lung sound sounds like snoring and may indicate sputum in the bronchi?

Back 141

Rhonchi

Front 142

What lung sound resembles crowing and may indicate an obstruction in the trachea or larynx?

Back 142

Stridor

Front 143

What does FBAO stand for?

Back 143

Foreign Body Airway Obstruction

Front 144

What are 3 disorders that may present "crackle" lung sounds as a symptom.

Back 144

- Pneumonia
- PE (Pulmonary Edema)
- CHF (Congestive Heart Failure)

Front 145

What are 2 disorders that may present "wheezing" lung sounds as a symptom.

Back 145

- Asthma
- Bronchitis

Front 146

What are 4 disorders that may present "stridor" as a symptom.

Back 146

- FBAO
- Anaphylactic or allergic reaction
- croup
- tumor

Front 147

What sound is produced by the heart as the AV valves (mitral and tricuspid) close?

Back 147

S1

Front 148

What heart sound represents systole (or the ejection phase)?

Back 148

S1

Front 149

What heart sound creates the peripheral pulses?

Back 149

S1

Front 150

What heart sound is produced by the closure of the semi-lunar valves (aortic, pulmonic)?

Back 150

S2

Front 151

What heart sound represents diastole (filling phase)?

Back 151

S2

Front 152

Describe the procedure for examining the heart/heart sounds.

Back 152

- inspect precordium for lifts/heaves and pulsations
- identify angle of louis, then use both bell and diaphragm to listen at the 5LICS-MCL.
- note whether rhythm is regular or irregular
- while listening, palpate radial pulse (notice relationship with heart sounds)
- obtain apical pulse by counting for 60 seconds

Front 153

What does PMI stand for?

Back 153

Point of maximum impulse

Front 154

Normally, the only palpable and visible pulse of the heart may be seen at the _____ area if the left ventricle pulsates against a thin chest wall.

Back 154

apical

Front 155

What is the normal location of an apical pulse?

Back 155

5LICS, MCL

Front 156

What is a normal AP-rate?

Back 156

60-100/min

Front 157

Describe normal heart sound findings.

Back 157

AP rate 60-100
S-1, S-2 regular and strong
PMI @ 5LICS-SCL

Front 158

What are examples of abnormal heart sound findings?

Back 158

- displaced PMI
- irregular rhythm
- abnormal sounds

Front 159

A displaced PMI may indicate what 2 disorders?

Back 159

- cardiomegaly (enlarged heart)
- heart failure

Front 160

What are some changes you may see in the elderly regarding the heart?

Back 160

- cardiac muscle decreases in size
- compliance decreases (due to valve and left ventricle stiffness)
- cardiac output decreases by 35% by age of 70

Front 161

What is the normal shape/contour of the abdomen?

Back 161

rounded or flat

Front 162

What is the order for examining the abdomen (3)?

Back 162

- visually inspect
- auscultate
- palpate

Front 163

How do you divide the abdomen?

Back 163

Use the umbilicus as a midpoint and divide the abdomen into RLQ, RUQ, LLQ, and LUQ

Front 164

When assessing bowel sounds, what is the normal timing between peristalsis sounds?

Back 164

5-20 seconds

Front 165

If bowel sounds occur faster than 5 seconds apart, what are they termed? What if they occur slower than 20 seconds apart?

Back 165

faster than 5 = hyperactive bowel sounds

slower than 20 = hypoactive bowel sounds

Front 166

Bowel sounds that fall within the range of 5-20 seconds are termed what?

Back 166

normoactive bowel sounds

Front 167

Describe the procedure for examining the abdomen.

Back 167

- Inspect, auscultate, and palpate IN THAT ORDER
- Inspect for shape, contour, symmetry, scars, bruises, pulsations, etc.
- Auscultate each quadrant for bowel sounds
- Palpate each quadrant for tenderness, masses, etc.

Front 168

Describe normal findings when examining the abdomen.

Back 168

- round or flat contour
- normoactive BS x 4
- soft, non-tender
- Suprapubic area flat

Front 169

What abnormalities might you find when examining the abdomen?

Back 169

- concave or sunken
- distended (large/firm)
- hyperactive or hypoactive bowel sounds
- Absent bowel sounds after listening for 3-5 minutes
- Tenderness/pain
- Guarding
- Scars/incisions
- Audible pulse

Front 170

A concaved abdomen might indicated what?

Back 170

malnourishment

Front 171

A distended abdomen might indicate what?

Back 171

fluid in the abdominal cavity

Front 172

An audible pulse (bruit) while examining the abdomen might indicate what?

Back 172

- aneurysm - life-threatening weakness in a blood vessel

Front 173

What is the purpose of auscultating bowel sounds of a patient who is just returning from surgery?

Back 173

- to determine that the anesthesia is leaving the body system (the return of bowel sounds indicates anesthesia is wearing off)

Front 174

Do narcotics increase or decrease peristalsis?

Back 174

decrease

Front 175

Describe the procedure for examining upper/lower extremities.

Back 175

- inspect for muscle development, tone, symmetry, skin integrity
- assess for musculoskeletal strength and equality by asking the client to squeeze the nurses fingers
- test ROM
- Assess for perfusion (skin color, temperature, pulses, capillary refill, movement, and sensation)
- Inspect nail beds for color
- capillary refill test
- access for clubbing
- Homen's test for lower extremities only

Front 176

Clubbing is caused by what?

Back 176

Long term respiratory disorders

Front 177

How do you examine a client for clubbing? What is the normal angle?

Back 177

Place nails of 2 opposing fingers together to identify if angle is greater than 160 degress (normal)

Front 178

Describe the capillary refill test. What is considered normal.

Back 178

Depress and blanch the nail bed for 5 seconds - release; color should return in less than 3 seconds (normal)

Front 179

What are normal findings for upper/lower extremities?

Back 179

- symmetrical muscle development and strength
- smooth, firm tone
- FROM
- Bilateral, DP/PT & radial pulses +2
- nail beds pink
- capillary refill less than 3 seconds
- no clubbing
- bilateral neg. Homan's signs

Front 180

Why should you not use the large toe to assess capillary refill?

Back 180

because of the high incidence of ingrown toenails - could be painful for the client

Front 181

Describe the Homan's test.

Back 181

-lift one foot off the bed by placing your hand under the ankle
- dorsiflex the foot
- inquire about calf pain
- if there is pain, repeat once to confirm
- if confirmed, assess the leg for signs of inflammation (redness, warmth, edema, tenderness)
- repeat on other extremity

Front 182

A client is in the hospital to be treated for deep vein thrombosis. What specific test would you exclude from the PE? Why?

Back 182

exclude Homan's test - you could dislodge the clot

Front 183

What abnormalities might you find when examining the lower extremities?

Back 183

- decreased muscle size/poor tone
- limited ROM
- Pulse abnormalities, irregularities in amplitude/rhythm
- Nail beds pale
- Cap. refill takes more than 3 secs.
- Clubbing (Chronic hypoxia)
- Positive Homan's sign
- Involuntary movements (tics, spasms, rigidity)
- Paresthesia (numbness, tingling)

Front 184

(def)

an abnormal sensation, typically tingling or pricking (“pins and needles”), caused chiefly by pressure on or damage to peripheral nerves.

Back 184

paresthesia

Front 185

What changes might you expect to see when examining the extremities of an older client?

Back 185

- decreased muscle mass, tone, and strength (Should be symmetrical)
- decreased ROM

Front 186

A Glasgow score of less than 6 indicates what?

Back 186

coma

Front 187

What 3 things does the Glasgow Coma Scale analyze?

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- Eye opening (up to 4 pts)
- Motor Response (up to 6 pts)
- Verbal Response (up to 5 pts)

Front 188

What is the maximum score (and normal result) for the Glasgow Coma Scale?

Back 188

15

Front 189

What is consider an abnormal score on the Glasgow Coma Scale?

Back 189

anything lower than 15

Front 190

What change might you expect to see when analyzing the mental status of an older adult?

Back 190

decreased ability to respond to multiple stimuli