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28 Cards in this Set

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Describe the components of health assessment and physical examination
1. Nursing Interview- includes biographical data, nursing health history chief complaint. present illness, past medical history, health patterns and Review of Systems

2. Behavioral Examination- includes the client in the psychological/emotional presence

3. Physical Examination-
a. initial (baseline)- as the client
enters the health care system
b. focused- ongoing; to assess
an area of concern or evaluate
an intervention.
*complexity determined by client need

4.Comprehensive- all 3
components: nursing interview,
behavioral and physical
examination
Describe the 4 techniques of examination
1. Inspection- visual examination; to look, to notice, to smell. The nurse observes shape, size, color, position, movement, symmetry, equality, etc.

2. Palpation- using the sense of touch; to feel , to stroke the surface of an area to detect its characteristics such as temp., vibration, turgor, texture, masses

3. Percussion- this technique not practiced in Basics

4. Auscultation- listening to sounds produced in the body.
Explain the procedures used to perform the physical examination for the skin

Describe the normal findings for the middle age and older adult client
PROCEDURE:
inspect all areas and palpate the non-mucous membrane skin surfaces

NORMAL FINDINGS:
Adult-
Color- color uniform, light to dark pink or brown
Moisture- dry; exceptions may be hands, face, axillae and skin
folds

Older Adults-
Color- Senile lentigo- brown age spots due to sun exposure.
May have pallor even in the absence of anemia. Skin may
appear thin and translucent
Explain the procedures used to perform the physical examination for the temperature of skin

Describe the normal findings for the middle age and older adult client
PROCEDURE:
dorsal surface of hand; compare temp of upper and lower extremities

NORMAL FINDINGS:
Adults- warm

Older Adults- extremities cooler to touch; decreased perspiration
Explain the procedures used to perform the physical examination for the texture of the skin

Describe the normal findings for the middle age and older adult client
PROCEDURE:
stroke the skin's surface with the pads of the finger

NORMAL FINDINGS:
Adult- smooth, soft, consistent; elbows, palms, and soles rougher/thicker
Explain the procedures used to perform the physical examination for the skin turgor

Describe the normal findings for the middle age and older adult client
PROCEDURES:
grasp with fingers and lift skin, then release it. Use the areas over the sternum or clavicle

NORMAL FINDINGS:
Adult- supple; when released the skin quickly snaps back to pre-tested position.

Older Adult- sluggish due to decreased elasticity and SC tissue; wrinkles, sagging
Explain the procedures used to perform the physical examination for edema

Describe the normal findings for the middle age and older adult client
PROCEDURE:
notice if the skin is shiny, stretched, or taut; inspect for symmetry. Measure in millimeters with tape measure. Depress the skin surface over a bony area if possible to observe for pitting. If the client has cardiac, renal or liver disorder or malnutrition, the nurse should measure abdominal girth at umbilicus to assess for ascites which is edema within the abdominal cavity. Compare daily weight.

NORMAL FINDINGS:
Adults- none, edema is never a normal finding
Explain the procedures used to perform the physical examination for skin lesions

Describe the normal findings for the middle age and older adult client
PROCEDURES:
Assess lesions for location, size, shape, color, texture, raised or flat, mobility, drainage, tenderness, etc.

NORMAL FINDINGS:
Adults- free of lesions

Older Adult- skin tags or senile keratosis (thickening), cherry angiomas (small, raised red papules), atrophic warts; all are clinically insignificant
Explain the procedures used to perform the physical examination for hair

Describe the normal findings for the middle age and older adult client
PROCEDURES:
inspect for even distribution, thickness; palpate for texture, oiliness, infestations (lice); gently tug on hair to assess for loss. observe hair over entire body

NORMAL FINDINGS:
Adults- thin/thick; straight/curly; fine/course; shiny/resilient; should not come out in clumps when gently pulled (> 5 strands) Normal male and female pattern of baldness is hereditary

Older Adult- thinning, graying; decreased on legs, axillae and pubic area; hormonal shifts may cause more on ears, eyebrows or males, on faces of females
Explain the procedures used to perform the physical examination for
the head/scalp

Describe the normal findings for the middle age and older adult client
PROCEDURES:
inspect skull for size, shape. Palpate skull for lesions using a rotating motion with the fingertips

NORMAL FINDINGS:
Adult- normocephalic, symmetrical; scalp shiny, intact, without lesions
Explain the procedures used to perform the physical examination for the face

Describe the normal findings for the middle age and older adult client
PROCEDURES:
inspect facial features for symmetry. Ask client to raise eyebrows, puff cheeks, smile

NORMAL FINDINGS:
Adults- symmetrical features; top of ears should align with the outer canthus of eyes; nose in midline
Explain the procedures used to perform the physical examination for eyes visual acuity

Describe the normal findings for the middle age and older adult client
PROCEDURES:
may ask to identify a commonly known object e.g. a watch, a pen, etc. avoiding asking to read. other visual test- light perception, hand wave, count fingers

NORMAL FINDINGS:
Adults-Intact if identifies common object

Older Adult-
Presbyopia- lens is unable to change shape to accommodate
close vision; has difficulty reading small print. starts in middle
years of life ~45 years
May have reduced adaptation to darkness and sensitivity to glare
Explain the procedures used to perform the physical examination for the eyelids

Describe the normal findings for the middle age and older adult client
PROCEDURES:
observe position of upper eyelids in relation to upper borders of the iris

NORMAL FINDINGS:
Adult- symmetrical; upper lids cover upper boarder of the iris; when closed the lids cover corners

Older Adults- May have have bilateral ptosis from loss of skin elasticity
Explain the procedures used to perform the physical examination for the sclera

Describe the normal findings for the middle age and older adult client
PROCEDURE:
inspect as client is asked to look up, down, side to side; nurse may open lids if client unable to do so.

NORMAL FINDING:
Adults- moist;
light skin client- color is
porcelain white
dark skin client- color is tan
with brown areas of melanin
Explain the procedures used to perform the physical examination for the conjunctiva

Describe the normal findings for the middle age and older adult client
PROCEDURE:
retract lower lid with nurse's opposite thumb; inspect as client asked to look upward

NORMAL FINDINGS:
Adults- pink, moist with some small blood vessels visible
Explain the procedures used to perform the physical examination for cornea/lens

Describe the normal findings for the middle age and older adult client
PROCEDURE:
inspect the cornea and lens for moisture and clarity

NORMAL FINDINGS:
Adults- moist, shiny without discharge, cloudiness or irregularities

Older Adults-
arcus senilis- benign (not
serious); bilateral gray ring
outlining the iris; lipid deposits.

cataracts- opacity or cloudiness
of the lens
Explain the procedures used to perform the physical examination for the pupils

Describe the normal findings for the middle age and older adult client
PROCEDURE:
inspect the pupils for color, shape, symmetry

NORMAL FINDINGS:
Adult- PERRLA, pupils equal, round, react to light, and accommodation
Explain the procedures used to perform the physical examination for the ears' hearing acuity and external structures

Describe the normal findings for the middle age and older adult client
inspect for position of ears; lift pinna or lobe upward to open ear canal. Inspect for cerumen, drainage. Occlude one ear with hand. Watch tick test at 1-2 inches or whispered word at 1-2 feet

NORMAL FINDINGS:
Adult- intact if hears ticking and/or whispered word; yellow/brown, waxy cerumen in external ear canals
Explain the procedures used to perform the physical examination for the nose

Describe the normal findings for the middle age and older adult client
PROCEDURE:
inspect position. Lift tip, inspect for moisture and drainage, equality of airflow

NORMAL FINDINGS:
Adult- midline; nares patent; without discharge; mucosa pink, moist

Older Adult- decreased sense of smell
Explain the procedures used to perform the physical examination for the mouth (lips, mucus membrane (mm), tongue, uvula, gums and teeth)

Describe the normal findings for the middle age and older adult client
PROCEDURE;
inspect lips for symmetry, color, moisture. Ask client to protrude the tongue and move it lt. and rt. Using penlight and tongue blade, inspect all mm (tongue, hard palate, gums, buccal mucosa, structures of the oropharynx) in a sweeping order. Inspect teeth.

NORMAL FINDINGS:
Adult- oral mucosa pink, moist; tongue and uvula midline; 32 teeth. Dark skinned clients may have brown patches of melanin on mm

Older Adult- decreased sense of taste; dry mm; may have lost teeth
Explain the procedures used to perform the physical examination for the neck

Describe the normal findings for the middle age and older adult client
PROCEDURE:
inspect for symmetry, position of head, trachea. Applying resistance, ask client to move head toward one side. Lower half of neck: move finger pads into space between trachea and sternocleidomastoid muscle (SCM), palpate one carotid pulse for rhythm, volume. Avoid using excessive pressure. Repeat with other carotid. Mentally compare for equality.

NORMAL FINDINGS:
Adult- full range of motion; trachea midline; carotid pulses equal, regular, strong

Older Adults- sagging of skin; may have weakened neck muscles; limited ROM
Explain the procedures used to perform the physical examination for the breasts

Describe the normal findings for the middle age and older adult client
PROCEDURE:
inspect breasts for symmetry, discharge, dimples. Ask about pain

NORMAL FINDINGS:
Adults- symmetrical; without dimpling or discharge; non-tender
Explain the procedures used to perform the physical examination for the thorax

Describe the normal findings for the middle age and older adult client
PROCEDURE:
Anterior-
inspect thorax for symmetry of the clavicles, ribs. Observe the client's breathing pattern, rate and rhythm, effort/work or breathing and if he is using accessory muscles. Observe if the excursion/expansion of both sides of the thorax is equal. Inspect for intercostal retractions or bulging. Compare transverse diameter (side to side) to the anterior- posterior (AP) diameter (front to back).
Posterior-
inspect for symmetry; spinal alignment (straightness); equality of excursion; skin integrity, presence of sacral edema

NORMAL FINDINGS:
Adults- symmetrical clavicles, ribs; costal angle equal to or less than 90 degrees. Equal expansion. Eupnea. Transverse > AP diameter. Posterior thorax- equal expansion; spine midline/straight. Skin intact without redness or sacral edema.

Older Adults- Muscle atrophy and chest rigidity, barreling- decreased expansion.
Explain the procedures used to perform the physical examination for lung sounds

Describe the normal findings for the middle age and older adult client
Compare sounds for equality from side to side
PROCEDURE:
Using the diaphragm, auscultate lung sounds for at least one full cycle of respiration at each location. Compare the volume of air heard at one point to the corresponding point on the other side. Begin over the trachea (bronchial sounds); then zigzag down, listening at the sternal boarders (SB) between 1-2 ICS (bronchovesicular). Instruct the client to take slow, deep breaths through the mouth. Auscultate the periphery (vesicular) by starting at the supraclavicular spaces (apex); proceed downward to the mid-fields. Listen at the midclavicular, anterior axillary and mid-axillary lines.
Posterior-
Auscultate between the scapulae (bronchovesicular). Auscultate the periphery by listening at the supra-scapular areas and zigzag downward at the mid-fields listening at the mid-scapular and posterior axillary lines. Auscultate the bases at the mid-scapular and posterior axillary lines

NORMAL FINDINGS:
Adult- No adventitious sounds.
Bronchial sounds over trachea;
harsh, loud; duration of
inspiration < expiration (IBronchovesicular sounds at 1-2
ICS, SB and posteriorly
between the scapilae. (I=E)
Vesicular sounds over periphery-
start at apex; compare side to
side for equality; proceed down
to bases; include lateral aspect
of chest; very quiet (I>E)
Explain the procedures used to perform the physical examination for the heart

Describe the normal findings for the middle age and older adult client
Sounds are produced by the closure of values. S1 is produced by the closure of the AV valves (contraction, systole)
S2 is produced by the closure of the semi-lunar valves (relaxation, diastole)

PROCEDURE:
inspect the precordium for lifts/heaves, pulsations. Identify the angle of Louis. Using both the diaphragm and the bell, auscultate at the 5LICS-MCL, noting the relationship of the heart sounds with the pulsation. The sound that produces the pulse is S1 . The other sound is S2; it is quiet and doesnt produce a pulse. For one full minute, count all S1 sounds to obtain the Apical Pulse.

NORMAL FINDINGS-
The only palpable (and visible) pulse may be seen at the apical area (mitral) if the left ventricle pulsates against a thin chest wall. It is called the Point of Maximum Impulse (PMI). Normal heart sounds are heard loudest at the 5LICS, MCL.
AP-rate 60-100/min; S1, S2, regular, strong. PMI at (state location)

Older Adults- Cardiac muscles decreases in size. As valves and left ventricle may stiffen, compliance decreases. Cardiac output (CO) decreases by 35% by age 70
Explain the procedures used to perform the physical examination for the abdomen

Describe the normal findings for the middle age and older adult client
PROCEDURE:
DIFFERENT SEQUENCE: inspect, auscultate, and then palpate. Use the umbilicus as a midpoint and divide the abdomen into 4 quadrants: RLQ, RUQ, LUQ, LLQ. Inspect the abdomen for shape, contour, symmetry, scars, bruises, pulsations, etc. Auscultate each quadrant for sounds of peristalsis (bowel sounds) and vascular sounds (bruit). Palpate each quadrant for tenderness, masses, etc.

NORMAL FINDING:
Round or flat contour; normoactive BS X4, bowel sounds (within 5-20 sec.) in all 4 quadrants; soft; non-tender. Suprapubic area flat
Explain the procedures used to perform the physical examination for the extremities

Describe the normal findings for the middle age and older adult client
PROCEDURES:
Upper extremities- inspect for muscle development, tone, symmetry, skin integrity. Assess for musculoskeletal strength and equality by asking the client to squeeze the nurse's fingers. Assess for perfusion- skin color, temp., pulses, capillary refill, movement and sensation. Inspect the nail bed for 5 seconds. Release, while observing if the capillaries refill in less then 3 sec. Assess for clubbing by placing the nails of two opposing fingers together to identify if angles are <160 degrees. Observe or test the client's ROM.
Lower extremities- Repeat above. Modify procedures to test strength and clubbing. To assess Homan's sign, lift one foot off the bed by placing the nurse's hand under the ankle. Dorsiflex the foot. Inquire about calf pain. If there is pain (Positive Homan's Sign), repeat the test only once to validate. Assess the leg for signs of inflammation: redness, warmth, edema, tenderness. Repeat the testing on the other extremity.

NORMAL FINDING:
Adult- Symmetrical muscle development and strength; smooth, firm tone. FROM. Bilateral radial, DP/PT pulses 2+. nail beds pink, capillary refill <3 sec. No clubbing. Lower extremity- bilateral negative Homan's signs

Older Adult- Decreased muscle mass, tone, strength, but should be symmetrical; decreased ROM.
Explain the procedures used to perform the physical examination for the mental status

Describe the normal findings for the middle age and older adult client
PROCEDUsing Glasgow Coma Scale. assess 3 faculties- eye opening (4); motor response (6); verbal response (5); Determine GCS Score

NORMAL FINDING:
Adult- Glasgow Coma Scale (GCS- 15 is maximum)

Older Adult- Decreased ability to respond to multiple stimuli.