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151 Cards in this Set

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Purposes of physical assessment

Gather baseline data
compare data with history
evaluate patient's changing health status
evaluate outcomes of care
When to perform physical assessment
Annually in office setting
At least every 8 hours in acute care
As needed for change in health status
Before and after treatments/proceedures
Considerations / prep before physical assessment
All appropriate tools and supplies
maintain standard precautions
ensure patient privacy and comfort
limit interrruptions
ensure adequate lighting
discuss procedure with patient
collect/review patient history
Consists of -
Biographical and demographic info
HPI (History of present illness) or Chief Complaint
Health History
Surgical History
Family History
Social History
Health care maintenance
cultural assessment
Patient history
5 skills of physical assessment
inspection, olfaction, auscultation, palpation, percussion
Notice these key aspects of general appearance and behavior
age, gender, race, signs of distress, body type, posture and gait, body movements, hygiene, grooming, dress, odors, affect, mood, speech
Physical assessment includes measurement of -
BP, pulse, respirations, temperature, O2 saturation, pain, height, weight, BMI
5 key aspects of pain
Onset and duration
Location
Intensity
Quality - i.e. throbbing, aching, sharp, burning
Pattern - factors that alleviate or exacerbate
Ouch, Life Is Quite Painful! (mnemonic)
Important history for neurological assessment
Use of medications/drugs including analgesics, alcohol, sedatives, hypnotics, antipsychotics, antidepressants, stimulants, recreational drugs

Symptoms relating to neurological imparement - headache, tremors, dizziness, vertigo, numbness, tingling, visual changes, changes in any of the 5 senses, weakeness, pain, changes in speech, behavioral changes

History of - seizures, paralysis, emotional stress, spinal cord injury, depression, anxiety, neurologic disease, congenital anomalies
Neurological portion of physical assessment includes -
LOC - Level of consciousness (if low, use Glasgow Coma Scale)
Behavior, cognition, orientation
Speech
Cranial Nerves
Pupillary response - PERRLA
Motor/sensory function
Glasgow Coma Scale
7 or less = coma
Rated in 3 areas:
Eye opening (1-4 points)
Verbal response (1-5 points)
Motor Response (1-6 points)
PERRLA
Pupils Even, Round (1-7 mm), Reactive to Light, and Accomodating (constricts close, dilates with distance)
Motor/Sensory portion of assessment
Moves all extremeties (document difficulty, weakness, numbness, tingling, etc) through normal ROM.
Balance
Gait
Strength of extremeties x4 - hand grasp, dorsiflection, plantar flexion of feet, leg abduction and adduction. Document as strong/weak, equal/unequal
Sensation to superficial touch (absent/present)
Palpation portion of cardiovascular assessment includes - (5)
Carotid, brachial, pedal pulses
PMI location
Palpate temperature of extremeties
Capillary refill
Peripheral edema
Inspection portion of cardiovascular assessment (3)
Inspect neck bilaterally (note Jugular venous distention -JVD)
Inspect nail beds for clubbing
Inspect extremeties for color, hair distribution, venous pattern (varicosities), scars, pigmentation, ulcers or edema
Auscultation portion of cardiovascular assessment -
Apical pulse
S1 first heart sound (lub) is closing of AV valves (mitral/tricuspid)
S2 second heart sound (dub) is closing of semilunar valves (aortic/pulmonic) - listen for extra sounds S3, S4
Regular or Irregular rate
Auscultate pulse rate for 1 minute with diapragm first then bell
Patient positioning for auscultation of cardiovascular system -
Sitting, Supine, Left lateral
Abnormal Heart Sounds - gallop
Extra sound(s) S3, S4
Abnormal Heart Sounds - click
mitral valve prolapse
Abnormal Heart Sounds - rubbing
Pericardial friction rub - may sound like squeaking or rubbing leather together caused by inflamation of pericardium
Abnormal Heart Sounds - squish/swoosh noise
Heart murmur - caused by incomplete valve closure (i.e. lub-swoosh-dub)
Pain symptoms related to cardiovascular system -
Chest Pain
Signs of occlusion - pain, pallor, lack of pulse, paralysis
Signs of phlebitis - localized tenderness, swelling, warmth, edema in one calf
Homan's sign - dorsiflexion of foot causes tenderness in calf
Important history related to lung assessment
Allergies
Tobacco/marijuana use
Any symptoms/history of impared lung function (persistent cough, voice change, SOB, orthopnea, activity intolerance, pneumonia, bronchitis, wt loss, fatigue, night sweats, fever)
Work environment
Risk for TB - HIV, low income, resident/employee of institutional facility
Family history of cancer, allergies, TB
Vaccination status for pneumonia, flu, TB
Inspection portion of lung assessment
Respiration rate and rhythm (regular or irregular)
Depth/Volume (deep, shallow, diaphragmatic, accessory)
Quality (labored, dyspnea, orthopnea)
Symmetry
Auscultation portion of lung assessment
Listen to at least 8 locations anteriorly, 12 posteriorly plus rt middle lobe (5th-6th intercostal space on rt midaxillary line).
Indetify qualities of breath sounds
Vesicular breath sounds
Normal, soft, breezy, low-pitched sounds. Created by air moving through small airways. Best heard over periphery. Inspiratory 3x longer than expiratory.
Bronchovesicular breath sounds
Normal, blowing sounds, medium pitch & intensity. Air blowing through large airways. Best heard posteriorly through large airways between scapulae and anteriorly to left and rt of sternum at 1st and 2nd intercostal spaces. Inspiration equal to expiration.
Bronchial breath sounds
loud and high-pitched with hollow quality created by air moving through trachea close to chest wall. Heard over trachea. Expiration longer.
Wheeze
high-pitched musical squealing heard most predominantly on expiration
Pleural Friction Rub
Course low-pitched sound resembling 2 pcs of leather rubbing together
Stridor
Harsh high-pitched sound heard on inspiration due to severe narrowing
Fine Crackles (rales)
Discontinuous high-pitched popping sounds heard during inspiration
Course Crackles
Loud, low-pitched bubbling and gurgling sounds. May decrease with coughing but will return shortly. Heard on early inspiration and expiration.
Rhonchi
Low-pitched musical snoring heard throughout cycle but most prominent on expiration. May clear with coughing. Usually caused by secretions in bronchial airways
Important history related to abdominal assessment
Use of anti-inflamatory meds, antibiotics, ETOH, laxatives
Assess changes/issues related to digestion
Family history of IBS, cancer, kidney disease, alchoholism, hypertension, heart disease
Patient history of abdominal issues, surgery, etc.
Inspection portion of abdominal assessment
Observe for evidence of pain (splinting, guarding, etc.)
Inspect skin for color, scars, venous patterns, lesions, striae (stretch marks), bruising, ostomies, tubes drains.
Inspect contour for symmetry, surface motion, masses, bulging, distention
Note position of umbillicus (flat, concave - should not have color difference or discharge)
Note movement and pulsations
Auscultation portion of abdominal assessment
Bowel sounds - audible passage of air and fluid that peristalsis creates.
Listen about 30 seconds per quadrand - typically about 5-35 sounds per minute
Listen 1 full minute before determining absence
Best time to auscultate is between meals
Absent bowel sounds indicate lack of peristalsis
Bowel sounds may be described as -
Normal, audible, absent, hyperactive, hypoactive
Abdominal vascular sounds are called _____ and are caused by _________
bruits, caused by narrowing of major blood vessels which disrupts flow
Location of 3 primary abdominal vascular sounds
Aorta - midline through abdomen
Renal Arteries - Upper quadrants anteriorly
Femoral Arteries - Lower quadrants
When examining the abdomen, remember to use skills in what order?
Always auscultate before palpating because palpation may significantly alter bowel sounds.
Ischemia
temporary deficiency of blood flow to an organ or tissue
Necrosis
death of cells, tissues and organs
Erythemia
Reddening of skin. Common but non-specific sign of injury, irradiation, inflamation
Excoriation
abrasion of skin or other organs
Atrophy
decrease in size of an organ or tissue
Keloid
exuberant scar that forms at site of injury or incision that spreads beyond initial boundaries of lesion
Macule
flat, non-palpable change in sckin color smaller than 1mm (freckle, petichia)
Papule
Solid elevation in skin. Palpable, circumscribed, smaller than 1cm
Nodule
Elevated solid mass, deeper and firmer than a papule. 1cm-2cm (Wart)
Tumor
Solid mass that extends deep through subcutaneous tissue. Larger than 1-2cm.
Wheal
Irregularly shaped elevated area or superficial localized edema. Varies in size (mosquito bite, hive)
Vesicle
Circumscribed elevation of skin filled with serous fluid smaller than 1cm (Herpes simplex, chicken pox)
Bulla
A large blister or skin vesicle filled with fluid (burn, friction blister)
Pustule
A small elevated skin lesion filled with white blood cells and sometiems bacteria or the products of broken down cells (as seen in acne vulgaris)
Ulcer
Deep loss of skin surface that extends to the dermis and frequently bleeds and scars. Varies in size (eg. Venous stasis ulcer)
Palpate skin for what 3 characteristics?
Temperature
Turgor
Edema
Acromegaly
a disorder caused by excessive secretion of growth hormone
Adventitiuos sounds
"extra" sounds that are abnormal
Alopecia
hair loss
Aneurysm
localized, blood-filled balloon-like bulge in the wall of a blood vessel.
Aphasia
Impairment of language ability. This class of language disorder ranges from having difficulty remembering words to being completely unable to speak, read, or write.
Arcus senilis
white or gray, opaque ring in the corneal margin (peripheral corneal opacity), or white ring around the iris. It is present at birth, but then fades; however, it is quite commonly present in the elderly. It can also appear earlier in life as a result of hypercholesterolaemia.
Atherosclerosis
(also known as ASVD) is a condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol.
Atrophied
reduced in size
Basal cell carcinoma
a cancerous skin lesion that is most common in sun-exposed areas of the body and frequently occurs in a background of sun-damaged skin. Rarely spreads.
borborygmi
hyperactive bowel sounds. Also known as stomach growling, rumbling, gurgling, grumbling or wambling, is the rumbling sound produced by the contraction of muscles in the stomach and intestines
bronchophony
Normally, vocal sounds heard through the chest wall are muffled. If fluid is compressing the lungs, the sound is transmitted more clearly. This effect is called bronchophony
bruit
When the lumen of a blood vessel is narrowed, it creates turbulent flow that produces a blowing or swishing noise. This sound is typically best auscultated by placing the bell of the stethoscope over the carorid artery. Thrill is a palpable bruit
capillary refill
is the rate at which blood refills empty capillaries. It can be measured by holding a hand higher than heart-level (prevents venous reflux), pressing the soft pad of a finger or toe until it turns white, and taking note of the time needed for the color to return once pressure is released. Normal refill time is less than 2 seconds.
cerumen
ear wax
chancre
is a painless ulceration (sore) formed during the primary stage of syphilis.
cherry angiomas
Ruby red papules (a normal age-related skin change)
cholecystitis
Cholecystitis is inflammation of the gall bladder.
clubbing
change in angle between the nail and nail base. Nail bed softening with nail flattening and often includes enlargement of the finger tips. Indicates chronic oxygenation problems.
conjunctivitis
infection of the conjunctiva of the eye
cyanosis
a bluish tint caused by lack of O2. Best observed in lips, nail beds, palpebral conjunctivae and palms. Could be due to cold-induced vascular constriction, anemia, airway defficiencies, or cardiovascular deficiencies.
dermatitis
can refer to many skin conditions with various symptoms including itching, dryness, and/or rash. Could be due to contact with allergen, dry environment, buildup of blood in lower legs due to immobility or other factors.
distention
swelling
dysrhythmia
failure of the heart to beat at regular successive intervals
ectropion
eyelid margins that turn out
eczema
skin condition characterized by dry, flaky areas
edema
Areas of the skin become swollen from a buildup of fluid in the interstitial spaces of the tissues. Direct trauma and impairment of venous return are two common causes of edema.
entropion
eyelid margins that turn in (eyelashes may irritate eye)
erythema
red discoloration of the skin (i.e. sunburn, inflammation, fever)
exopthalmos
bulging eyes
exostosis
is the formation of new bone on the surface of a bone. Exostoses can cause chronic pain ranging from mild to debilitatingly severe, depending on where they are located and what shape they are.
goniometer
a tool for measuring range of motion
Hemorrhoids
varicosities of the anal canal
hernia
protrusion of abdominal organs through the muscle wall
hirsutism
a condition which causes females to develop more male-like hair growth. Vellus hair of upper lips, chin, cheeks and body becomes thicker and darker.
hydrocephalus
a buildup of cerebrospinal fluid in the ventricles
hypertonicity
when describing muscle, it means increased tone, a tight muscle that will provide considerable resistance to sudden passive movement. Continued movement of the joint will eventually cause the muscle to relax
indurated
hardened
integument
skin, hair, scalp, and nails
jaundice
yelow-orange discoloration typically due to poor liver function. Best observed in client's sclera.
kyphosis
also called roundback or Kelso's hunchback, is a condition of over-curvature of the thoracic vertebrae (upper back).
leukoplakia
thick white patches on the mucosa that are often precancerous lesions. More common in heavy smokers and alcoholics.
lordosis
an abnormal inward curvature of a portion of the lumbar and cervical vertebral column.
melanoma
an aggressive form of skin cancer
metastasize
the spread of a disease from one organ or part to another non-adjacent organ or part.
murmurs
sustained swishing or blowing sounds heart when auscultating the heart. Due to increased flow through a normal valve, a stenoic valve, or through a leaky valve
nystagmus
an involuntary rhythmical oscillation of the eyes
occlusion
blockage
orthopnea
shortness of breath (dyspnea) that occurs when lying flat.
ototoxicity
injury to the auditory nerve. May be a result of high maintenance doses of antibiotics (eg aminoglycosides)
palpation
involves using the hands to touch body parts to make sensitive assessments. Use different parts of the hand for different types of palpation. For example, use the dorsal side of hand to assess temperature and fingertips for detecting masses. Light intermittent pressure is best because heavy prolonged pressure reduces sensitivity of the fingers. Always assess painful areas last.
pancreatitis
is inflammation of the pancreas.
paralytic ileus
is a disruption of the normal propulsive ability of the gastrointestinal tract. Often a bowel obstruction
peritonitis
inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera.
petechiae
pinpoint-sized red or purple spots caused by small hemorrhages in the skin layers. Could indicate serious blood-clotting disorder, drug reactions, or liver disease.
phlebitis
an inflammation of a vein, usually in the legs.
PMI
Point of maximal impulse, where heart beat is heard most clearly due to close proximity of apex of heart to chest wall. 5th intercostal space on left midclavicular line
polyps
tumor-like growths
ptosis
abnormal drooping of the eyelid over the pupil
Scoliosis
lateral spinal curvature
senile keratosis
a thickening of the skin commonly seen in elderly clients - a normal age-related skin change
squamous cell carcinoma
a cancerous skin lesion that is more serious than basal cell carcinoma. It develops on the outer layers of sun-exposed skin. These cells may travel to lymph nodes and throughout the body.
stenosis
narrowing
striae
stretch marks
syncope
loss of consciousness
tactile fremitus
Also called vocal fremius. Vibrations of sound waves (generated when the patient speaks) that can be palpated externally. The accumulation of mucus, collapse of lung tissue, or presence fo lung lesions will block vibrations from reaching the chest wall.
thrill
a continuous palpable sensation like the purring of a cat (may be related to heart murmur or palpable bruit).
turgor
the skin's elasticity - used in assesing hydration or edema
varicosities
swollen tortuous veins that are common in older adults and rarely cause problems
ventricular gallop
S3, occurs just after S2 and creates a heart rhythm with a Ken-tuck-y sound to it. Due to a premature rush of blood into a ventricle that is stiff or dilated as a result of heart failure and hypertension
vocal fremitus
also called tactile fremitus. Vibrations of sound waves (generated when the patient speaks) that can be palpated externally. The accumulation of mucus, collapse of lung tissue, or presence fo lung lesions will block vibrations from reaching the chest wall.
whispered pectoriloquy
Certain lung abnormalities cause the whispered voice to become clear and distinct when auscultated through the chest wall. This effect is called whispered pectoriloquy
Important characteristics of sounds -
Frequency (pitch)
Loudness
Quality (i.e. blowing, gurgling)
Duration
Odor of alcohol on breath may indicate
indicates alcohol consumption or diabetes
odor of ammonia in urine may indicate
UTI, renal failure
odor of feces in mouth or vomitus may indicate
bowel obstruction
foul-smelling stools in infant may indicate
malabsorption syndrome
Sweet, fruity ketones on breath may indicate
diabetic acidosis
stale urine smell on skin may indicate
uremic acidosis
Musty odor on casted body part may indicate
infection inside cast
Fetid, sweet odor on tracheostomy or mucus secretions may indicate
infection of bronchial tree
To assess for substance abuse, use
CAGE questions - tried to CUT DOWN? Others ANNOYED? Ever feel GUILTY? Use substance as EYE-OPENER (to feel normal)?
A weight gain of ____ lbs in one day indicates fluid retention problems. A loss of more than ___ % in one month or ___% over 6 months may indicate a serious problem
gain of 5lbs in one day
loss of 5% in 1 month or 10% over 6 months is rapid weight loss.
Drug abuse associated with diaphoresis
sedative hypnotic (including alcohol)
drug abuse associated with spider angiomas
alcohol, stimulants
drug abuse associated with burns (especially of fingers)
alcohol
drug abuse associated with contusions, abrasions, cuts, scars
alcohol, other sedative hypnotics
drug abuse associated with "homemade" tattoos
Cocaine, IV opiods (to mask injection sites)
Drug abuse associated with increased vasculatiry of face
alcohol
drug abuse associated with red, dry skin
phencyclidine (PCP)
Splinter hemorrages (red or brown linear streaks in nail bed) may indicate
trauma, cirrhosis, diabetes mellitus, or hypertension
Dilated pupils may indicate
glaucoma, trauma, neurological disorders, eye medications (eg atropine), or withdrawal from opioids
pinpoint pupils are a common sign of
Opioid intoxication
A heart murmur heard between S1 and S2 is called a
systolic murmur
Pitting edema scale
1+ Mild pitting, less than 2mm indentation, no perceptable swelling of the extremety
2+ Moderate pitting, 2-4mm indentation subsides rapidly
3+ Deep pitting, 4-6mm indentation remains for a short time, extremety looks swollen
4+ Very deep pitting, 6-8mm indentation lasts a long time, extremety is very swollen