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113 Cards in this Set

  • Front
  • Back
Purpose of physical exam
a) Provides indication of the person’s overall health status
b) Can provide additional information about the clinical significance of reported symptoms
c) Can provide indication of how person is responding to treatment already given
2) Assessment Data
b) Subjective
c) Objective
3) Nursing Assessment takes a __ approach with client and family
b) Holistic
i) physical
ii) psychosocial
iii) spiritual
4) Types of Assessment
ongoing partial
comprehensive examination
i) A comprehensive assessment is performed with a health history and complete physical examination.
ii) This type of examination is done on admission to a hospital or when first meeting a client at home or in an office or clinic setting if appropriate.
b) Ongoing Partial Assessment
i) This is conducted at regular intervals such as the beginning of each shift or at each home visit, and may be repeated as needed
c) Focused Assessment
i) A focused assessment is conducted to address one specific problem.
d) Emergency Assessment
i) A rapid assessment used to detect life threatening situations
ii) Airway, breathing, circulation come first
5) Physical Assessment i) Gathering equipment
(1) Stethoscope
(2) BP cuff
(3) Thermometer
(4) Scale
(5) Measuring Tape
(6) Reflex hammer
(7) Otoscope
(8) Snellen Chart
(9) Vaginal spectulum
(10) Gloves
(11) Mask
(12) Gown
(13) Goggles
(14) Lubricant
c) Positioning During Exams
i) Supine
ii) Semi-fowlers
iii) Supine
iv) Dorsal recumbant
v) Side lying
vi) Lithotomy
vii) Knee chest
viii) Sims
6) Inspection
a) The process of deliberate, purposeful observations performed in a systematic manner.
b) One area at a time.
c) Compare one side to the other.
7) Palpation
a) Uses sense of touch to gather information that cannot be obtained through inspection alone.
light vs deep palpation
i) Light
(1) Dorsal Surface of Hand
(a) Light Palpation
ii) Deep
(1) Palmar Surface of Hand
8) Percussion
i) Act of tapping a person’s skin in order to set up a vibration that can be interpreted by you the health professional.
Pleximeter vs Plexor? When used?
pleximeter (non-dominant hand middle finger)
plexor (dominant hand middle finger)

Used for indirect percussion
c) Percussion Tones
1) Flatness, Soft, Thigh
2) Dullness, Medium, Liver
3) Resonance, Loud, Normal Lung
4) Hyperresonance, Very Loud, Emphysema
5) Tympany, Loud, Air in Abdomen (drum like)
9) Auscultation
a) Use of stethoscope to listen to body sounds.
b) Listen for:
i) pitch
ii) loudness
iii) quality
iv) duration
1) General Survey
i) First Component of any exam
iv) Uses inspection technique including sight, smell, and, hearing
v) Includes observation of appearance and behavior, taking vital signs, and measuring height and weight
b) Level of Consciousness
i) awake and alert, or lethargic, or stuporous, or comatose
General survey observations
i) Body build, posture, gait
ii) Hygiene, grooming
iii) Signs of Illness
iv) Affect, attitude, mood
v) Cognitive process
2) Skin, Hair, Nails a) Inspect
i) overall condition, color, vascularity, lesions,
ii) body odors
2) Skin, Hair, Nailsb) Palpate
i) temperature,
ii) moisture,
iii) turgor,
iv) texture
v) nails-capillary refill,
Abnormalities in Skin Color
(1) Erythema
(a) redness,flushed
(2) Cyanosis
(a) gray or blue
(3) Jaundice
(a) yellow: light to dark
(4) Pallor
(a) pale, ashen
ii) Abnormalities in Skin Turgor
(c) In elderly client
(i) decreased turgor MAY be normal finding
(d) Dehydration
(i) turgor delayed
(e) Edema
(i) difficulty in lifting skin fold
d) Age Variations ii) Older Adult
(1) Wrinkles, dryness, scaling, decreased turgor
(2) Raised dark areas (senile keratosis)
(3) Small flat age spots (senile lentigines)
(4) Small round red spots (cherry angioma
4) Eyes c) use of light source to check for
i) reaction to light
ii) consensual reflex
iii) accomodation
iv) convergence
v) extraocular movements
vi) peripheral vision
5) Ears
i) Whisper Test
ii) Weber’s Test
iii) Rinne’s Test
(1) Both tests with tuning fork for hearing acuity
(a) compare air conduction of sound to bone conduction
(2) Normal finding is that air conduction is better than bone conduction
6) Nose and Mouth is
is the beginning of the respiratory and the GI systems
g) Neck Inspection
i) Chains of lymph nodes extend into face under chin and down the lateral neck and on the posterior neck.
ii) Thyroid Gland is assessed for
(1) size, shape, masses, nodules, tenderness, and symmetry.
iii) Assess vascular system
(1) JVD?, Carotids
iv) Auscultate the carotids
7) Thorax and Lungs
c) Best if patient is sitting, make adjustments for bed ridden patient.
d) General Inspection of Chest
i) Observe color, shape, contour, and breathing patterns.
(1) Color should be the same as the face.
(2) Shape should be transverse is greater than the anterior/posterior diameter.
(3) Breathing pattern should be even and 12-20 breaths/minute
ii) Palpation of chest checking for
tenderness, temperature, muscle development, and fremitus.
Palpation of chest normal findings and abnormal findings
(2) Normal findings would be warm skin, well developed muscles, no tenderness, and equal voice vibrations throughout.
(3) Abnormal would be cool or excessively dry or moist skin, muscle assymetry, tenderness, unequal fremitus, abnormal breathing patterns or expansion.
percussion of chest
(a) Flat
(b) Hyperresonance
(c) Dullness
(d) Hollow, loud, low pitch, and long duration (normal)
(e) Heard over bone (normal)
(f) Emphysematous lung (abnormal)
(g) Heard over solid mass or fluid (abnormal)
i) Bronchial sounds
(1) Blowing hollow sounds normally heard over the trachea.
ii) Bronchovesicular sounds
(1) Medium pitched, medium intensity blowing sounds normally heard over upper chest posteriorly and anteriorly.
iii) Vesicular
Soft low pitched sounds heard over remainder of lung fields.
v) Adventitious Breath Sounds
(1) Crackles (or rales)
(a) fine or coarse
(2) Wheezes
(3) Gurgles (rhonchi)
9) Cardiovascular Inspection and Palpation
(1) for peripheral pulses and perfusion noting strength of pulse and color of extremity.
pulse grading
0 through 4: absent through bounding
v) Auscultation of Heart
(1) Aortic
(2) Pulmonic
(3) Tricuspid
(4) Mitral
(6) Normal Heart Sounds(7) Abnormal Heart Sounds
(a) S1
(b) S2

(a) S3
(b) S4
(c) Murmurs
b) Normal Age Related Variations for heart
i) Newborns/Children (3) Presence of S3

ii) Older Adult
(2) Increased SBP and DBP
10) Abdomen assesment order
i) inspection
ii) auscultation
iii) percussion
iv) palpation
Normal assesment order
11) Musculoskeletal System
a) Use inspection and palpation only
e) Muscle Strength
d) Palpate and inspect joints for tenderness, symmetry, and swelling
g) Inspecting Spinal Curves
(1) Kyphosis: Increased thoracic curve, seen in elderly.
(2) Lordosis: Exaggerated lumbar curve seen in pregnancy, obesity, childhood
(3) Scolioisis: Lateral curvature that forms S shape to spine (often school screenings identify)
h) Orthopedic Checks
i) Also called extremity check, vascular check, splint check or neurovascular checks
ii) Checking an extremity that has been compromised
iii) Check temperature, swelling, pulse, sensation, discoloration, pain, drainage and record and if necessary report changes
12) Neurological System
c) We use inspection and touch for this exam.
e) Twelve Cranial Nerves
1 olfactory
2,3,4, and 6- eyes
5 Trigeminal face sensation
7 Facial facial muscles
8 acoustic
9 Glossopharyngeal swallowing
10 vagus speaking
11 spinal accessory shoulder
12 Hypoglossal tongue
f) Reflex Grading Scale
i) 0 no tone, +1 low tone, +2 normal,
ii) +3 brisker than average but may be normal
iii) +4 hyperactive often indicative of disease.
g) Glasgow Coma Scale
: Score of 0 to 15
i) Eye Opening,
ii) Motor Response,
iii) Verbal Response
13) Diagnostic Testing
c) Diagnostic test results confirm or repute physical assessment findings. Nurses obtain results for the chart
13) Diagnostic Testing Nurses are responsible for
assisting with obtaining consent, preparation, scheduling, and patient support following procedures.
a) A total Health Assessment will include
the Health History and the Physical Assessment.
1) The History of the Nursing Process Defined by Hall in 1955
to describe the work of nurses
d) ANA Congress for Nursing Practice (1973) recognized
the 6 step Nursing Process as the model for nursing practice.
2) Steps of the Nursing Process
a) Assessment
b) Diagnosis
c) Outcome Identification & Planning
d) Implementing
e) Evaluating
3) Characteristics of the Nursing Process
a) Systematic
b) Dynamic
c) Interpersonal
d) Outcome oriented
e) Universal
4) Nursing Process - Purpose
a) Helps the nurse manage each client’s care
i) Holistically
ii) Scientifically
iii) Creatively
4) Nursing Process Focus
i) on the unique human response
5) Problem Solving and the Nursing Process
c) Scientific
b) Trial and Error
d) Intuitive Thinking
e) Critical Thinking
6) Critical Thinking
b) A systematic way to form and shape one’s thinking.
c) Solves problems creatively
d) Thinking with a purpose
The Four Blended Skills
1) Cognitive
2) Technical
3) Interpersonal
4) Ethical/legal
Cognitive Skills
a) Use scientific rationale when planning patient care
b) Identify the purpose or goal of your thinking
c) Determine if the knowledge is accurate, complete or relevant
Technical Skills
a) Involves psycho motor skills
b) Includes the mastery of the manual skills essential to the nursing process
Interpersonal Skills
a) Caring behaviors are essential to nursing practice
b) Promote the dignity and the respect of patients
c) Communicate caring through patient interactions
Ethical/Legal Skills
a) Accept accountability for the care you delegate
b) Voice your concerns over the unmet needs of your patients
c) Document patient needs
d) Report incompetent, unethical, or illegal practice
9) Characteristics of Critical Thinkers
a) Independent thinker
b) Fair minded
c) Intellectually courageous Intellectually humble
e) Demonstrates good faith and integrity
f) Possesses curiosity and perseverance
g) Creative
h) Disciplined
i) Confident
11) Concept mapping
a) A critical thinking approach to care planning
b) An instructional strategy that links key concepts
c) A visual map of why relationships exist among patient problems
Nursing Assessment
i) First step of the nursing process
iii) A patient data base is started or revised
1) Unique Focus of Nursing Assessment
a) Gathering information about the client
b) Does not duplicate medical assessments
c) Strives to determine the client’s RESPONSE to health problems or illness
d) No other health professional does this
2) Types of Assessments
a) Initial
b) Focused
c) Emergency
d) Time Lapsed
i) Objective data
(1) includes the Physical Assessment and what you observe
iii) Uses the senses
ii) Subjective Data
(1) the Nursing Health History and what the patient tells you
(2) Health history told by pt
b) Data Sources primary vs secondary
i) Primary
(1) most reliable
(2) Client/Patient
ii) Secondary
(1) Family, significant other
(2) Health record
(3) Lab results
(4) Diagnostic procedures
(5) Health team members
(6) Literature/Internet
a) Data needs to be
i) Complete
ii) Factual and accurate
iii) Relevant
iv) Purposeful
Nursing History
h) Focus should be getting to know the person
i) Should capture the uniqueness of the person
j) Information gained helps nurse identify patient strengths and weaknesses
1) The Interview Purpose
i) Obtain a health history that contains information about the client’s health status
2) Phases of the Interview
i) Preparatory
ii) Introduction
iii) Working
iv) Termination
b) Preparatory Phase
iv) Use a non-judgmental approach
v) Ensure privacy (family presence only if patient approves)
vi) Conduct interview at opportune time
c) Introduction phase
i) State purpose
iii) Introduce self
iv) Clarify roles
d) Working Phase
i) Focus on the patient
ii) Use therapeutic communication skills
iii) Gather information
e) Termination
i) Conclude carefully, not abruptly
ii) Encourage client/family to give nurse additional information in order to help nursing staff to plan care
3) Problems Related to Data Collection
a) Inappropriate organization of the data base
b) Omission of data
c) Inclusion of irrelevant data
d) Failure to establish rapport
e) Failure to observe appropriate behavior
f) Failure to update the data base
g) Failure to document accurately, clearly & timely
a) Confirm or verify discrepancies
i) Between objective and subjective data
ii) Between sources, client and family or record
a) Cues
i) pieces of information obtained through assessment;
(1) an indication that something may be wrong
(2) can be objective or subjective
b) Inference
i) assignment of a meaning to the cue
ii) is the Nursing DX
(1) do not use the medical problem as dx. Use it as a strength to help identify the response to form RN Dx.
Complete Health Assessment
1) Two components
a) Nursing history
b) Physical assessment
ii) Biographical Data
(1) Patient initials, age, sex, marital status, religion, occupation, education
subjective data needed for health assesment
ii) Biographical Data
iii) Reason for seeking healthcare
iv) Patients opinion of own general health
v) Activities of Daily Living
vi) Pattern of Nutrition
vii) Elimination
viii) Activity/exercise
ix) Rest/sleep
x) Safety
xi) Previous illnesses (major) & hospitalizations
xiv) Wellness Practices:
xv) Medications
xvi) Family History
xvii) Family Support:
xviii) Psychosocial History:
b) Review of Systems
a brief subjective account as reported by the patient of any recent signs or symptoms associated with any body system.
i) Average Life expectancy
(1) Women- 80.5
(2) Men- 75.4
old age groupings
ii) Young Old
(1) 60-74
iii) Middle Old
(1) 75-84
iv) Old-old
(1) The over 85 group
(2) Fastest growing segment
v) Elite old
(1) Over 100!
1) Ageism
a) Form of prejudice
b) Deep seated uneasiness on the part of the young and middle aged adults
c) Personal revulsion or distaste
d) Consequences of Ageism
i) People distance themselves from elders
ii) Don’t see elders as “like them”
iii) Elder is viewed as being less than human
3) Examples of Negative Attitudes
a) Raising the voice when speaking to an elder
b) Providing no or less privacy during care
c) Referring to elders as cute
d) Talking about elder in their presence
a) Myths on older adults
i) Most elders are in nursing homes
ii) Being elderly means being “senile”
iii) Older adults do not care how they look
iv) Most elderly have bladder problems
Aging Changes General Status
(1) Less efficiency of physiologic processes
(2) Fragile balance of homeostasis
(3) More vulnerable to stressors
(4) Decreased reserves
Aging Changes Integumentary
(1) Wrinkles- decreased elasticity
(2) Dryness
(3) Balding
(4) Skin pigmentation-moles
(5) Thickened nails
iv) Neurologic age changes
(1) CNS responds more slowly to multiple stimuli
(2) Cognitive/behavioral response is delayed
(3) Temp perception and pain regulation become less efficient
(4) Sense of balance declines, fine movements become more difficult
(5) Sleep at night shortens, naps more common
v) Special Senses age changes
(2) Diminished hearing acuity
(1) Diminished visual acuity
vi) Musculoskeletal age changes
(1) Muscle mass, strength decrease
(2) Bone demineralization
(3) Stiff joints
(a) Overall mobility slows.
(4) Height decreases
(5) Decrease in subcutaneous tissue and weight
vii) Cardiopulmonary age changes
(1) Blood vessels-
(a) Less elastic, rigid
(b) Fatty plaque deposits
(2) Lower extremity edema and cooling
(3) Body less able to increase HR and cardiac output with activity
viii) Gastrointestinal age changes
(1) Digestive juices diminish
(2) Nutrient absorption decrease
(a) Anemia
(3) Decreased peristalsis
(a) Constipation
(b) Indigestion
ix) Genitourinary age changes
(1) Blood flow to kidneys decrease with diminished cardiac output
(a) Waste products filtered more slowly
(b) Bladder capacity decreased
(2) Men
(3) Hypertrophy of the prostate
7) Older Adult Health
i) Chronic illness
ii) Accidents and injuries
iii) Dementia, Depression
iv) Elder Abuse
e) Elder Abuse
i) Neglect
ii) Abuse
(1) Physical
(2) Emotional
(3) Financial
f) Dementia
i) Various organic disorders that effect cognition
ii) Alzheimer’s disease
(a) Most common
iii) Affects brain cells
iv) Progressive
8) Gerontologic Nursing
a) Specialty of nursing concerned with assessment of health and functional status of older adults and planning, implementing health care and services to meet needs as well as evaluating the effectiveness of care
b) Gerontology
i) Scientific and behavioral study of all aspects of aging and its consequences
c) Meeting Healthcare Needs
c) Meeting Healthcare Needs
i) Major goals:
(1) Promote health
(2) Prevent illness/injury
ii) Areas of concern
iii) Nursing actions
9) Care Settings
a) Retirement communities
b) Continuing care retirement communities
d) Acute care
e) Home care
f) Assisted living
g) Adult day care
h) Respite care
i) Long-term care