Physical Assessment Flashcards

Terms Definitions
bronchovesicular
What Sound?
Splits 2
Vascular lesions:Tiny punctate hemorrhages, less than 2 mm, round and discrete, dark red, purple, or brown in color.
petechiae
CN I: Name/Function/Test
Olfactory/Smell/Familiar Smell
Primary Skin Lesions: Encapsulated fluid-filled cavity in the dermis or subcutaneous layer, tensely elevating skin.
cyst
Hair
Assesses for distribution (hirsutism- excess hair), texture, infestation; fullness or loss (alopecia)
normal pulse on pulse scale
+2
CN IV:: Name/Function/Test
Trochlear/superior oblique muscle/extraoccular movement that is down nasally
hyperresonant
tympany is often heard over
plagiocephaly
oblique shape of a head
Surcumscribed elevation of the skin that is filled with serous fluid.
Vesicle
Common Shapes and Configurations of Lesions: ___, distinct, individual lesions that remain seperate.
discrete
keloid
hypertrophied scar - over grown scar
Wheal
irregularly shaped fluid collection - hive
Level of consciousness where patient cannot be aroused, even with use of painful stimuli; may have reflex activity(if no reflexes present, patient may be in coma)
comatose
Cardinal: Down and temporal
Inferior rectus/CN III
Cardinal: Up and nasal
Inferior oblique/CN III
hypoglossal
How do you assess CN XII
Wheezes
Rhonchi is caused by what mechanism
Client Positioning
Sitting; Supine; Dorsal recumbant; Lithotomy; Sims; Prone; Lateral recumbant; Knee-chest;
What can deminish skin turgor?
Edema or dehydration
___ occurs with disease of the semicircular canals in the ears, a paretic eye muscle, multiple sclerosis, or brain lesions.
nystagmus
eyes and vision
Assess
1. External Structures
a Eyelids, inspect for ability to blink; Position (ptosis -droopy eyelid) b. lesions, c conjunctive: palpebral(lid) color(pink) or lesions. d. sclera color white not red or yellow e. cornea assess for opacity or scratch f. pupil size, equality, shape, reaction to light and accommodation. PERRLA

2. Extra ocular Movement - 8 cardinal fields of gaze
3. visual fields - periphery
4. visual acuity - 20/20
5. internal structures -ophthalmoscope
Ascites
The abnormal accumulation of fluid in the peritoneal cavity
What sounds are heard over peripheral lung fields?
Vesicular
What kind of murmur is this?
Decrescendo murmur.
Increased tactile fremitus is indicative only of:
Consolodation from pneumonia
I
A normal palpable pulse is what grade
II IV VI
What does PERLA stand for
Auscultation
should be last except for abdominal assessment
brachycephaly
caused by premature closure of the coronal suture; head has a short, broad appearance; can be seen in tri21 or Apert syndrome
the transfer of heat enery when a liquid is changed to a gas...
evaporation
The transfer of heat from one object to antoher with direct contact....
conduction
Babinski's reflex
occurs when the great toe flexes toward the top of the foot and the other toes fan out after the sole of the foot has been firmly stroked. This is normal in younger children, but abnormal after the age of 2.
Adventitious (abnormal)
breath sounds when air passes through narrowed airways filled with fluid or mucus; superimposed over normal breath sounds
Crackles - fine, high pitched crackling sounds; best heard on inspiration at the base caused by reinflation of the alveoli
Rhonchi - low piched gurgling; moaning, snoring quality; heard between scapula and lateral to sternum; clears with coughing
Wheeze- high pitched, squeaky; best heard on expiration; heard anywhere.
Skin Color
Should be appropriate for skin tone. Abnormalities of skin color include pallor decreased Hbg supply - appears as a loss of red tones in dark skin, best seen in the nail beds, lips, oral mucous membranes. Cyanosis is blueness in light skin( decreased oxygenation) is seen as ash gray in dark skin central Cyanosis best seen in lips, buccal mucosa, and the tongue. Jaundice - yellow skin from liver disease due to increased bilirubin
erythema -redding of the skin inflammation and rashes.
Type of skin lesion that is palpable, circumscribed, solid elevation and smaller than 0.5cm
Papule
Is splitting of S2 into Ao and Pulmonic a normal finding
Yes
Labia majora
what external genitalia is inside the labia majora
diaphragmatic excursion
The normal span in cm for diagphragmatic excursion
Palpation: Light Palpation
uses light intermittent pressure to assess for areas of tenderness and superficial abnormalities
cystic hygroma
most common neck mass; fluctuant mass that can be transilluminated and usually found laterally or over the clavicles
What is the first part of the physical examination?
Vital signs.
___ is perception of two images of a single object.
diplopia
Peripheral Vascular System Assessment
Assesment of BP, palpation of peripheral pulses, inexpection of jugular and peripheral vessels, pulses at temporal, coratid, apical, radial, brachial, femoral, popliteal, dorsalis pedis and anterior tibial Document pulse as 1+ to 4+ with 1+ being weak and 4+ being bounding 2+ being nomal what we expect. Look for JVD.
inspection of skin tissues to deteermin perfusinon to the extremities.
Arterial insufficiency - cool extremity, dec or absent pulse, color changes, color pale
Venous insufficiency - normal temperature, normal pulses, color changes; skin changes - edema, color dark.
Deep Vein Thrombosis (DVT) - Horman's Sign: Knee flexed - pain in calf with dorsiflexion of foot. Not performed if pt is dx'd with thrombus.
Edema fluid accumulation in the tissues assess by pressing firmly iwth the thumb - usually over shin or medial maleoulus of foot. graded on scale of 1+ to 4+ 1+ dissapears imediatly, 2+ 10 sec to dis, 3+ greater then a min 4+ 2 to 5 mins
Describe what S4 is?
An extra heart sound (pathologic) which represents atrial contraction and is caused by a stiff left ventricle. Timing of sounds has same rhythm as "Tennessee".
last longer during inspiration
bronchial breath sounds last longer during inspiration or expiration
anterior and posteriorfornices
what separates upper end of vagina from isthmus of uterus
internal OS
what formed by junction of cervix and vagina
noted in pneumonia, pulmonary edema, luminary fibrosis
rhonchi sound like what
barlow
adduct the hips by using the thimb to apply outward and backward pressure over the inner thigh
When does assessment begin?
When the nurse first meets the client.
Vascular lesions: A raised bright red area with well-defined borders about 2 to 3 cm in diameter.
Strawberry Mark (Immature Hemangioma)
What kind of arterial pulse wave is this?
Normal pulse wave.
Pupils equal reactive to light and accomodation
what is a rectocele
Inspection, auscultation, percussion, palpation
When percussing the liver, where do you begin percussing
Erb-duchenne paralysis (upper arm paralysis)
the most common brachial plexus injury; injury to the fifth and sixth cervical nerves; adduction and internal rotation of the arm, wrist is flexed; associated with diaphragm paralysis (2nd to phrenic nerve injury)
How do nurses demonstrate accountability for their nursing care?
By evaluating the results of nursing interventions.
What is a systolic click?
Midsystolic click due to mitral valve prolapse. High pitced sound heard with the diaphragm at LLSB, frequently followed by a ejection murmur.
area at the apex of the heart, fifth intercostal space, mid clavicular line.
What is fremitus
Where is tricuspid regurge best heard
lower left sternal borderb. radiation to right sternum to xiphoid area or midclavicular line. Never to axilla.
central lesion will only affect the lower face.
CN III is called what
Klumpke paralysis (lower arm paralysis)
injury to seventh and eighth cervical nerves and the first thoracic nerve; hand is flaccid; Horner syndrome can occur
What are the 5 skills of conducting a physical assessment?
Inspection, palpation, percussion, auscultation, and olfaction.
What is physiologic splitting of S1 due to? Where would you auscultate to hear it?
Tricuspid and mitral valves not closing simultaneously. Mitral component is louder than the tricuspid component. Heard best at tricuspid listening point (left lower sternal border) and does not vary with respiration. Not pathological.
This is due to increased transmission through consolidated or airless lungs.
whispered sounds heard more clearly through consolidated lung tissue when using what assessment technique
along the lower left sternal edge
Crackles (old name was rales) occur when
What is responsible for the first heart sound (S1)?
Closure of AV valves (tricuspid and mitral).
When is pan-systolic murmur best heard
starts with S-1 and ends with S-2 without a gap between murmur and heart sounds.
What would you hear with a innocent/physiologic murmur? Why?
Low grade murmur head at 2nd-4th left interspaces. Innocent murmurs result from turbulent blood flow, probably generated by ventricular ejection of blood into the aorta from the left and occasionally the right ventricle. Common in children and yound adults.
Physiologic murmur is due to temporary increase in blood flow in predisposing conditions such as anemia, pregnancy, fever, and hyperthyroidism.
is best felt lateral to the tendon of F.C.R. at the wrist, and also in the anatomial snuff box
Where is the femoral artery located
This nerve is tested by first observing the tongue (while in floor of mouth) for fasciculations. If present, fasciculations may indicate peripheral CNXII dysfunction. Next, the patient is asked to protrude tongue and move tongue in all directions
Where is the lesion if CN XII is affected
Olfactory
Smell
CN VI
Abducens
fissure
linear crack athlete's foot
AC>BC(ear)>(mastoid)
Cranial nerve II is
Primary Skin Lesions: Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule.
nodule
Nodule
Solid Mass Deeper than papule
skin lesion:circumscribed elevation of skin similar to vesicle but filled with pus; varies in size (acne, staph)
pustule
corneal reflex
CN VI is what
Kasabach-Merritt syndrome
cavernous hemangioma with thrombocytopenia
What is inspection?
the process of observation.
Excessive secretion of growth hormone from the piturary, after puberty, creates an enlarged skull and thickened cranial bones is called?
acromegaly
Ears
Exam includes inspection/ palpation of external parts, inspection of canal and drum with otoscope and auditory acuity

1. Auricle: inspect for position (pinna level with corner of eye) compare each side, look for lesions
2. canal - look for drainage. tympanic membrane requires otoscope
3. auditory acuity gross hearing my be assed by client's response to voice. Whisper test using 2 syllable words such as baseball.
Nose
External nose inspect for any deviations in shape size color, flaring or discharge. check for patency (clear nasal passage way) check for sense of smell.
frontal /maxillary sinuses palate for tenderness.
Usually no visible pulsations are seen, except for around what?
PMI
Cardinal: Straight nasal
Medial rectus/ CN III
CN V: Name/Function/Test
Trigemenal/Motor:controls masseter and temporal muscles;Sensory: pain, temperature, and light touch sensation; also sensory portion of corneal reflex/Motor: have pt clench jaw and palpate muscles;Sensory: have pt close eyes and then check the three
acidic
The acidic environment helps prevent what
II
A prominent pulse is what grade
acrocephaly
coronal and sagittal sutures close early; skull has a narrow appearance with a cone shape at the top; can be seen in Crouzon and Apert syndromes
Which lung has 3 lobes?
The right side
Vascular lesions: A reddish-blue, irregularly shaped, solid and spongy mass of blood vessels.
cavernous hamangioma (mature)
Turgor
Elasticity, hydration - assess on back of hand, poor turgor skin remains tented > 3 sec
Glasgow Coma Scale
objective numeral scale for measurement of consciousness. Measures eye opening, verbal response and motor response. The Higher the score the more normal the level of functioning.
What assessment is not used in assessing the heart?
percussion
CN VIII: Name/Function/Test
Acoustic

- hearing and balance (cochlear & vestibular)

- hearing test; test for lateralization (Weber test; should be heard equally)
Superior, Medial, Inferior Rectus, Inferior Oblique
CN IV is
S2
1. closure of aortic and pulmonic valve
whisper pectoriloquy
louder, clearer voice sounds because of increased transmission of high pitched components when using what assessment technique
facial nerve palsy
cause: intrauterine position or forceps; compression of the 7th cranial nerve; symptoms: ptosis, unequal nasolabial folds, and asymmetry of facial movement
the transfer of heat away by air movement.
convection
___ is the resulting skin level depressed with loss of tissue; a thinning of the epidermis.
atrophic scar
Ileus
Obstruction of the intestine due to it being paralyzed. The paralysis does not need to be complete to cause ileus, but the intestine must be so inactive that it prohibits the passage of food and leads to blockage of the intestine
stenosis
is an abnormal narrowing in a blood vessel or other tubular organ or structure. It is also sometimes called a "stricture" (as in urethral stricture).

This of the vascular type are often associated with a noise (bruit) resulting from turbulent flow over the narrowed blood vessel. This bruit can be made audible by a stethoscope
What sounds are heard over bony and well developed muscle tissue?
Flat
CN VII: Name/Function/Test
Facial

- Motor: muscles of facial expression/Sensory: anterior 2/3rds of tongue for taste

-Motor: raise both eyebrows, frown, try to hold eyelids together, show upper and lower teeth, smile, & puff out both cheeks Sensory: use taste
vaginal orifice
Located on either side of vaginal orifice and slightly posterior are what glands
taste, ant. 2/3 of tongue
What is CN IX
labia minora
Located at anterior end of labia minora is the
Abducens
What EOM does the Abducens, CN VI test
cervix
what is formed by junction of isthmus and cervix
pleural effusion
what is the normal sequence when performing an abdominal exam
Palpation: Deep Palpation
pressure that depresses tissue 2-5cm and is used to assess underlying organs. May be applied bimanually and sensations are assessed with the palmar surface of the fingers and the finger pads
pectus carinatum- def, causes
"pigeon chest", sternum is protuberant; causes: Marfan and Noonan syndrome
At what age should women have a routine mammogram?
Age 40
Vascular lesions: A large, flat macular patch covering the scalp or face, frequently along the distribution of cranial nerve V. The color is dark red, bluish, or purplish.
Port-Wine Stain (Nevus Flammeus)
What sounds are heard over fluid or a solid mass?
Dullness
Describe what S3 is?
An extra heart sound (pathologic) which represents ventricular filling and is caused by volume overload (congestive heart failure). Can be normal in youth, athletes and pregnant women. Timing of sounds has same rhythm as "Kentucky".
near large bronchi2. over consolidated lung
normal breath sounds include
caput succedaneum
diffuse edema of the soft tissues of the scalp, may extend across suture lines, resolves within days
Low set ears are a sign of which chromosome abnormality?
Down Syndrome
Other heart sounds
S-3 rapid fillng of the ventricle with blood; heard following S-2. can be normal in young adults and children; pathologic in elderly
S-4 - atrial contraction and thought to result from stiffened left ventricle directly precedes S-1 heard in the elderly.
Extra sounds; snaps and clicks refer to valves; aortic and mitral steno sis, prosthetic valves.
Murmurs: swishing or blowing sounds caused by Forward flow through a steno tic valve increased flow through a normal valve, backward flow through a valve that fails to close
Murmurs should be identifed as systolic (between S-1 and S-2) or diastolic (between S-2 and S-1) Try to identify the grade of murmur; Grade 1 barely audible to grade VI loud and may be heard without the stethoscope
If no other sounds are heard document that S-1, S-2 heard without extra sounds.
What is a summation gallop?
It signifies an S3 and S4.
Weakness in turning head in one direction indicates problem in contralateral CN XI, while weakness in shoulder shrug indicates ipsilateral CN XI lesion .
CN XI is called
Auditory or formally the vestibulochochlear
What special sensory function does facial nerve have
What are the two diastolic murmurs
Aortic regurge and mitral stenosis
Who is most at risk for alterations in their skin?
Neurologically impaired clients, chornically ill, orthopedic clients, clients with deminished metal status, poor tissue oxygenation, low cardiac output,or inadequate nutrition.
basic heart sounds
S-1 - produced by the closure of the atrioventicular(av) valves, mitral and tricuspid - loudest at mitral area. The sound is a dull, low pitched "lub"
S-2 produced by closure of the aortic and pulmonic(semilunar) valves, is higher piched shorter and is the "dub" sound. Heard best at the base (aortic and pulmonic areas). S-2 is normally louder than S-1
noise induced - most common - occupationally involvedb. trauma - skull fx (basilar)c. tumors
Cranial nerve I major function
fremitus refers to palpable vibrations transmitting through the chest wall.
How do you assess for fremitus
air (ie: gas bubble)
A dull sound when percussing the lungs indicates what
third left intercostal space left sternal boarder
Tricuspid valve area:where is it located
glabella reflex (blink reflex)
tap gently over he forehead and the eyes will blink
What is included in the assessment of the integument?
skin, hair scalp and nails.
Describe the grading of systolic murmurs.
Grade 1: Very faint, heard after listener has “tuned in”, not heard in all positions.
Grade 2: Quiet, but readily heard, not necessarily in all positions.
Grade 3: Moderately loud, heard in all positions to varying extent.
Grade 4: Loud with a palpable thrill.
Grade 5: Very loud, with thrill, heard with stethoscope in partial contact with chest.
Grade 6: Very loud, with thrill, can be heard with stethoscope off the chest or with the naked ear.
Cranial Nerve IX and X are tested by the gag reflex, or alternatively, having the patient say "Ah.." while looking for symmetrical elevation of the palate. The gag reflex is performed by touching the posterior pharyngeal wall with a tongue depressor
What is CN X
Weber - lateralizes to good ear
When a pt has sensorineural hearing loss, and you conduct a Rinne test, what can you expect to find
Describe the location of the cardiac auscultatory points? How do auscultate them?
Listen to all auscultatory points with the diaphragm of the stethoscope, then listen with the bell at the tricuspid and mitral listening points.
-outer: pink, squamous epithelium and connective tissue; lies in folds called rugae which allow vagina to expand– second: submucosal; contains blood vessels, nerves, lymphatic channels– third: smooth muscle– fourth: connective tissue and va
Is the normal vaginal PH alkaline or acidic
What postion can you put a patient in to better hear a aortic murmur?
Have them exhale and lean forward.
can be felt in the angle between the medial end of the clavicle and the sternomastoid muscle.
Where is the brachial pulse located
What is cyanosis and where are the assessment locations?
Bluish color of the skin. You would assess the nail beds, lips, mouth, skin.
What would you hear with a aortic stenosis? What is the mechanism?
Often harsh (may be musical at apex), crescendo-decresendo sound heard at right 2nd interspace. Significant aortic valve stenosis impairs blood flow across the valve, causing turbulence, and increases left ventricular afterload. Causes are congenital, rheumatic, and degenerative; findings may differ with each cause. Other conditions mimic aortic stenosis without obstructing flow: aortic sclerosis, a stiffening of aortic valve leaflets associated with aging; a bicuspid aortic valve, a congenital condition that may not be recognized until adulthood; a dilated aorta, as in arteriosclerosis, syphilis, or Marfan's syndrome; pathologically increased flow across the aortic valve during systole can accompany aortic regurgitation.
usually at 5th interspace just medial to left MCL.
Why is it important to know what the PMI is
CN III
Oculomotor
cranial nerve I
Olfactory
coloboma
key-shaped defect in iris
Primary Skin Lesions: Superficial, raised, transient, and erythematous; slightly irregular shape due to edema (fluid held diffusely in the tissues).
wheal
Skin Moisture
excessive sweating (diaphoresis); excessive dryness (elderly)
What sounds heard over stomach?
Tympany
CN III: Name/Function/Test
Occulomotor/

-Moves inferior, superior, and medial rectus muscles and inferior oblique and the levetator palpebrae muscle;consensual pupillary reaction

-extraocular movement tests for nasal, upper nasal, upper, and lower temporal fields; check for ability to move eyelid up and down with no ptosis
spinal accessory
CN XII is called
deep blue sclera- seen in:
OI
Tears are secreted from what gland?
lacrimal
Primary Skin Lesions: Turbid fluid (pus)in the cavity. Circumscribed and elevated.
pustule
Bulla
large elevated, fluid filled - hives
scar
formation of fibrous tissue after healing
Neck
identify and assess jugular veins, jugular venous distention- refers to pulsation in the interior jugular vein (or exterior) and is an indication of Rt heart failure. patient should be at 45degree angle and not the level of the pulsations relative to the sternal angle. ROM, Lymph nodes palpate and document andy enlarged or painful nodes. Identify carotid artery, trachea, trapezius, and sternocleidomastoid muscles
What sounds heard over emphysematous lung tissue?
Hyperresonance
Cardinal: Down and Nasal
superior oblique/CN IV
Trapezius, Sternocleidomastoid
How is CN XI tested
Inspection
Inspect for color, size, shape, symmetry, position, and any abnormalities*** use additional light for body cavities
dolichocephaly/scaphocephaly
sagittal suture closes prematurely and there is a restriction of lateral growth of the skull resulting in a long narrow head
Even yellowing of the sclera extending up to the cornea, indicating jaundice is called?
scleral icterus
Assessing the Abdomen
order of assessment inspection, auscultion, percussion, palpation

Skin look for scars, rashes, lesions, striate, vascularities
Conture - is it flat, rounded, protuberant, scaphoid(concave); distended, the 6F's: flatus, fetus, fat, fluid, feces, and fatal groth.
Pulsation usually the abdominal aorta
Auscultion: to assess bowel sounds, vascular sound; in pregnancy, FHT's are heard
Frequancy of bowels sounds approx 5-20/min listen 3-5 min before reporting that they are absent.
Describe what you hear as audible diminished- hypoactive-absent- hyperactive, borborygmi-really noisy.
Percussion: to identify organ size and detect fluid, gass or masses.
Palpation: to detect tenderness, distention (ascities vs flatus), pressence of masses(bladder)? light palpation - use fingertips with fingers together in a light dipping motion (1/2- 1" deep)
skin lesion that is irregulaly shaped, elevated area or superficial localized edema; varies in size (eg. hive, mosquito bite)
Wheal
CN XII: Name/Function/Test
Hypoglossal

- moves the tongue

- have patient move tongue from side to side
Medially
What ventricle does the PMI orginate from
clitoris
The boat-shaped area or fossa formed by the skin folds of the labia major and labia minora is referred to as the
Areas to Include
Enter your back text here.
Cavernous hemangiomas
large red, cyst-like, firm, found anywhere on body
What is the first technique the nurse employes during a physical exam?
Inspection.
Bulging of both eyes can be caused by....
hyperthyroidism.
Acne is example of what primary skin lesion?
pustule
Head and Face
assessed by inspection and palpation
inspect size, symmetry, note any deformities ( Normocephalic is a medical term referring to a person whose head and all major organs of the head in a normal condition and without significant abnormalities)
Pustule
Pus fill < 1 cm - acne impetigo
What sounds are heard over inner lung fields?
Bronchial
both
crackles may be noted when a patient has what pathological condition
Apex
Low pitched sounds are best heard with what part of the stethoscope
consolidation (ie: PNA)
a pneumothorax produces what sound when percussed
same side
What visceral organs are affected by CN X (Vagus)
Preparing the environment
comfortable room temp; privacy; quiet; adequate lighting; firm examination table; bedside table or work tray for equipment; any additional equipment needed to ensure client's comfort
ortolani
abduct the hips by using the middle finger to apply gentle inward and upward pressure over teh greater trochanter
ptosis
drooping of an upper eyelid cause by third cranial nerve paralysis or weakness in the levator muscle
What is auscultation?
Listening to sounds produced by the body.
Macule
Flat up to 1 cm in size - frekle
S2 sounds are which heart valves?
aortic and pulmonic (DUB)
tracheal, bronchial, bronchovesicular, vesicular
Vesicular lung sounds are heard where
Rinne - AC>BC
what are some causes of sensorineural hearing loss
Superior Oblique
How is the sensory portion CN V tested
When does an early diastolic murmur begin
begins with S-2
brushfield spots
white or yellow spots on the iris; seen in down syndrome or may be normal
What pattern of comparison is used to auscultate the lungs?
side to side.
Abdomen division for assesment
done by dividing the abdomen into quadrants or into 9 sections. Quadrants- imaginary lines crossing tat the umbilicus. RUQ, LUQ, LLQ & RLQ
9 sections terms most often used are epigastric, umbillical, right and left inguinal, suprapugic.
Organs in each quadrant
RUQ: liver gall bladder, duodenum, colon, head of pancreas.
LUQ: stomach, Spleen, Colon, Pancreas.
RLQ: appendix, overy, urethra, kidney, colon, uterus
LLQ: colon, ovary, urethra, kidney, uterus
What are some characteristics of mitral regurge
variable intensityd. medium pitche. blowing qualityf. gets louder with inspiration
obstruction of external auditory canal (EAC)b. T.M. (tympanic membrane) perforationc. serous otitis media (SOM
sensorineural hearing loss occurs when
What are the five sound produced by percssion?
Tympany, resonance, hyperresonance, dullness, and flatness.
What is an opening snap?
Opening sound of mitral valve (rarely tricuspid) indicating pathology. High pitched sound heard best with the diaphragm in early diastole.
Cranial Nerve V is tested by assessing facial sensation to light touch and pain on the forehead (V1), cheeks (V2) and chin (V3). This is performed with use of a cotton wisp and safety pin.
What is CN V
Vagina􀀩 Uterus􀀩 Cervix􀀩 Fallopian tubes􀀩 Ovaries
The avg. length of the vagina is how long
How do you assess capillary refill? What is an appropriate finding?
Blanch nailbed for several seconds. Normal refill should be less than 2 seconds.
What would you hear with a pulmonic stenosis? What is the mechanism?
Often harsh , crescendo-decrescendo sound heard at the 2nd and 3rd left interspaces. Pulmonic valve stenosis impairs flow across the valve, increasing right ventricular afterload. Congenital and usually found in children. In an atrial septal defect, the systolic murmur from pathologically increased flow across the pulmonic valve may mimic pulmonic stenosis.
in conductive hearing loss, sound lateralizes to the affected ear
When performing a Rinne test in someone with a conductive hearing loss, what can you expect to find
More valuable in detecting consolidation, infarction, or etelectosis.
in performing egophony, when a pt says "ee" you hear what with the stethascope
Techniques of Assessment of the heart
Inspection - look for lift at apex.
Auscultation - client should be assessed in supine position with head up to 45 deg.; examiner stands at right side. Use diaphragm for basic sounds; bell for murmurs and extra sounds.
Identify the heart rate, rhythm, bell for murmurs aortic, pulmonic, mitral.
Paralysis of the entire left side of the face would be a result of what kind of nerve damage?
Peripheral (between pons and muscle) nerve damage of the right CN VII (facial)
the passage of air through an airway obstructed by secretions
Aortic valve area:where is it located
What would you hear with a mitral regurgitation? What is the mechanism?
Harsh, holosystolic sound heard at the apex. When the mitral valve fails to close fully in systole, blood regurgitates from left ventricle to left atrium, causing a murmur. This leakage creates volume overload on the left ventricle, with subsequent dilatation. Several structural abnormalities cause this condition, and findings may vary accordingly.
is indicated by a line from the superior angle of the popliteal fossa to the middle of the back of the leg at the level of the tibial tuberosity.
Where is the posterior tib artery located
What would you hear with a hypertrophic cardiomyopathy? What is the mechanism?
Harsh sound heard at the 3rd and 4th interspace. Massive ventricular hypertrophy is associated with unusually rapid ejection of blood from the left ventricle during systole. Outflow tract obstruction of flow may coexist. Accompanying distortion of the mitral valve may cause mitral regurgitation.
The muscular innervation of CN VII is tested by first observing the patient's face while at rest, specifically looking for nasolabial fold flattening or drooping of the corner of the mouth. The patient is then asked to raise eyebrows, wrinkle forehead, sh
A peripheral lesion of VII, like in bells palsy, causes what type of facial paralysis
past illnesses,surgeries,hospitalizations,allergies,otc,herbal supplements and general habits are considered?
Health history
LIFE CYCLE INFLUENCES
-Transcultural-Developmental-Subjective/Objective data collection-Risk factors-Functional Assessment (ADL)-Environmental-Self-Care behavior
What is DVT?
deep vein thrombosis.
TYPES OF DATA BASE
-Complete-Episodic-Follow up-Emergency
What is the normal bladder capacity?
400ml-500ml
motor responses
eyes openstick out tonquesqueeze fingermove arms and legs
A normal lung sound is called?
resonance
choreiform
jerky and quickpresent in Sydenham's chorea
OBEJECTIVE DATA
What the health professional observe-inspecting-palpating-auscultation-percussingLab results
DATA COLLECTION
Leads to nursing diagnosis-interpret data-identify related factors-document diagnosis
During an assessment, a patient may loose interest because of a weak attention span but what might this also demonstrate?
Fatigue
When assessing your patient's eyes, ears, nose, which of the four assessment techniques could you use?
Inspection, Palpation
When assessing your patient's BLEs, which of the four assessment techniques could you use?
Inspection, Palpation
the bell of a stethoscope during auscultation detect____ pitched sounds?
low
sign of abnormal LOC
Drowsydifficult to asakendifficult answering questionsmemory defectirritable
EMERGENCY DATA BASE
-Rapid collection of data-Complied with life-saving measures-Diagnosis must be swift and sure
What is palpation?
technique of pressing on patient's tissues to evaluate texture, temperature, dampness, organ location and size.
What is the maximum score a patient can achieve on the glasgow scale?
15
True or False: When the semi-lunar valves close, this stage is referred to as S2.
TRUE !
Which of the breath sounds is a high-pitch, loud "harsh" sound created by air passing through the trachea?
Bronchial
the condition that brought the client to health care facility is
Chief Complaint
during inspection observe?
skin color and texturecheck for lesionshair distributioncan be out of bedgaitstanceverbal,behavioral responsesmental status
ability of lens to adjust to objects at varying distances
accommodation
SUBEJECTIVE DATA
What the person relates during history taking
How do check stereognosis?
if patients ability to recognize familiar objects. Close their eyes and put a quarter in their hand.
What is the normal findings of palpating the abdomen?
Non-distended, soft/firm, non-tender
Define intentional tremor.
a tremor that occurs only with movement of the affected extremity.
What portion of heart sounds are called systole?
S1 -> S2
You are listening to your patient's breath sounds at their lung bases. You hear fine, short, interrupted, crackling sounds that are high in pitch when your patient both breathes in and out. After coughing, you still hear the sound. Most likely you are hea
Crackles or Rales
While performing palpation determine?
position of the organs,size and consistency.fluid accumulationpainmassessurface of hand for vibration, temperature and moisture/dry.
Asterixis is seen in
metabolic encephalopathy due to kidney or liver failure
Where is the s2 sound best heard?
base of the heart.
What are some perfusion assessment questions?
Energy level, fatigue, dizzy, swelling.
What is phlebitis?
Inflammation of the vein. Vein may be hard, painful, and red.
What part(s) of the large intestine is found in the right lower quadrant, and what major organ(s) are found here?
Ascending colon. appendix
Define receptive aphasia.
The loss of the ability to comprehend spoken or written words
When using palpation, what can you assess on the patient?
texture, temperature, vibration, position, size, motility of organs, masses, distention, pulsation, and pain upon pressure
Eye opening glasgow coma scale response are?
Spontaneous when a person approaches4in response to speech3only in response to pain2do not open even to pain1record C if closed by swelling
Where is dullness percussion sounds heard?
organs or masses, (kidney, liver). When a patient has pneumonia, this sound is heard in the lungs.
When doing health history assessment, what 4 areas of information do you want to cover?
biographical data, history o resent illness, past medical/surgical history (including allergies, meds, hospitalization) family history
What is non-pitting edema?
swelling is evident, but no pit is formed with pressure.
Where do you check capillary refill and how long should it take for the color to change?
finger or toes, 3 seconds
What is pitting edema?
Leaves an indent in the tissue with pressure
What is pleural friction rub?
dry, grating sounds as the pleural cavity is rubbing against.
Define expressive aphasia.
The loss of the ability to express one self.
When subdividing the abdomen into four quadrants, what body part acts as the vertex?
The belly button / umbilicus
motor responses glasgow coma scale responses are?
obeys a simple command6feels painful stimuli5withdraws from painful stimuli4decorticate posturing3decerebrate posturing2 no motor response to pain1
What is the concept definition of oxygenation?
The process that maintains oxygen levels necessary for the survival of living cells.
What is infiltration of an IV?
Fluid is perfusing outside the vein into the interstitial space. Causes swelling and pain.
What is the concept definition of perfusion?
Exchange of blood, gases, fluids between the vessels, tissues and organ systems.
4 is to abdominal quadrants as 9 is to _______.
is to regions
In explaining your assessment to the patient, what are three things to do?
> Make the patient comfortable
> Provide privacy for them
> Answer any ? they may have
What is the minimum urinary output?
30ml per hour (50ml per hour is better)
what is +4 on the edema chart?
deep pitting, indentation lasts a long time, area is very swollen.
Before beginning your assessment what tasks should be performed?
wash hands, don PPE if required, offer comfort, protect privacy of patient, introduce yourself.
What form do you use with light palpation?
Always do light palpation first
Go gently in a circle so that the skin is slightly depresssed
sound or tone of the vibration curing percussion is determined by?
body area or organ percussedNormal lung soundsliver soundsmuscle sounds
What does a barrel shape chest indicative of?
lungs have increased in size, due to emphysema.
For testing lower body strength, what can a nurse do?
the nurse places his/her hands at the planter surface of the balls of the patient's feet and asks the patient to "push my hands away". Also, you ask the patient to raise their foot off of the bed and touch your hand with their toes
What does FLACC stand for and what is it used for?
Face, Leg movement, Activity, Cry, Consolability. Its used for infants and young children who can't use other scales.
True or False: The carotid arteries and the radial arteries are the only two locations to beat in synch with the heart since they are the closest to the heart
FALSE ! Only the carotid arteries beat in synch with the heart
Crackles and Rales are most commonly heard where ?
at the bases of the lower lung lobes
True or False: When doing light and deep palpation, you should do the palpate the tender areas first to identify the critical areas of your assessment.
FALSE ! Deeply palpate the tender areas last - and don't do it on patients with abdominal pain!
What do you want to note about a patients urine?
color, clarity, odor, and sediment if there is any.
Jugular vein distention could be a sign of ?
R sided heart failure - the atrium not allowing blood to flow freely to the heart
What do you want to assess about a patient's bowel movements?
how many, pattern (once a day, every other) watery/formed, hard/soft, color, shape, presence of blood. If it is liquid measure in ml.
In the past, why were peanuts listed on the Plain M&Ms ingredient list?
They were used for the candy coating ! ;-)
When do you use the bell end of the stethoscope?
To listen to heart sounds which are low pitched.
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