NU 215-4: Physical Assessment

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Pcc Nursing Physical Assessment Teacher: Miss Scott 2010-Fall

Inspection, Palpation, Percussion, Auscultation

General Exam technique's in order: (4)

Inspection, Auscultation, Percussion, Palpation

Exam techniques for the GI system in order: (4)

Inspection

Process of observation to gather data

Inspection

__ begins as soon as you see you pt & cont. through out

AV Fistula/ Shunt

Vein & Artery that are surgically sown together to increase bld flow

Palpation

Use of hands & fingers to gather info through the sense of touch

Back of hand

___ is used to feel for temp

ulnar side (pinky side) of hand

___ (__) is used to feel for vibrations

1 cm

Light Palpation = __

4 cm

Deep Palpation = ___

Ulnar

__ palpations = Vibrations

Dorsal

__ palpations = Temperature

Palmar

__ palpations = Masses

Percussion

Involve striking objects against another producing vibrations & sound waves

indirect percussion

__ __ = tap middle finger of your dominant hand on pt

Diaphragmatic Excursion

__ __ = measure movement of diaphragm

False, nurses do not generally do percussions

T/F Percussions are part of the nurses PA

Tympani

(sounds of percussion) Gastric bubble; drum like sounds

Hype-resonance

(sounds of percussion) COPD Lung (Chronic Obstructive Pulmonary Disease)

Resonance

(sounds of percussion) Lung

Dullness

(sounds of percussion) Liver (or most organs)

Flatness

(sounds of percussion) over muscle

Auscultation

Listening for sounds produced by the body

True

T/F When Auscultating, you should ALWAYS listen on skin surface

Diaphragm

Part of stethoscope to listen to High pitched sounds

Bell

Part of stethoscope to listen to Low pitched S3, S4, Bruit (heart sounds)

close you eyes

A way to help you focus when asculating

Pulses, Pitting Edema, Breath sounds, Abnml girth & Calf measurements

(5) some Places to compare right to left

False, Toward

T/F ear pieces tipped AWAY from pt. when asculating

True

T/F a nurse should NOT hang her stethoscope around her neck

Sphygomanometer

BP Cuff is known as a ___

Doppler

Used to hear the pulse you may not be able to feel

Otoscope

Look in ears

down

When using the otoscope on children, pull ear __ & back

up

When using the otoscope on adults, pull ear __ & back

Ophthalmoscope

Used to assess eyes

Snell chart

Eye chart to check farsighted; uses Ex, Xs, & Os

Monofilament

used to Tests sensations (important for diabetics)

Webber Test & Rhine Test

__ Test & __ Test are two tests used with a tuning fork

Webber test

(Type of tuning fork test) Touch middle of forehead (sound should be the same)

Rhine Test

(Type of tuning fork test) Bone conduction (hold against base of mastoid process (@ base of ear)

Gonimeter

Checks flexion & extension

wear gloves

Standard precautions: when you think you may come into contact with body fluids, you should ....

Chief Complaint

CC

History of present illness or problem

HPI

Review of Systems

ROS

CC; HPI; Past medical history; Family history; Personal & Social history (exercise, smoke, living conditions, bobbies, martial status); ROS; & Physical Exam

Interview & Health History: (7)

Temp, Pulse, Resp, bld Pressure, & Pain

Vital sign order (5)

Nml VS Ranges:
96-100 degrees F
60-100
12-20
90-120/60-80 140/90+
92-100
0

Nml VS ranges
Temp:
Pulse:
Resp.:
BP: Report when:
Oxygen Saturation:
Pain:

Trends

__ is highest and lowest of the VS (Range)

Pyrexia

__ = Fever

Afebre

__ = no fever

Operator error
Hypothermia

(Reasons for abnml) Temp. (low):
# 1 reason = ... OR __ = poor perfusion (sign of death)

Hypothermia (low temp)

Poor perfusion (sign of death)

Fever, Sepsis (infection in bld)

(Reasons for abnml) Temp. (high): (2)

True

T/F If pt has had a infection for a while, their temp DECREASES

Heart Block (MI), Overdose, Athlete, Hypoxia, OR beta blockers (bld pressure meds that decrease HR)

(Reasons for abnml) Pulse (low): (5)

Stress, Activity, or Pyrexia (fever)

(Reasons for abnml) Pulse (high): (3)

Narcotic use (CNS depressant/ aka opioids); or Resp. failure

(Reasons for abnml) Resp. (low): (2)

Hypoxia, metabolic or resp. Acidosis (Hyperventillation)

(Reasons for abnml) Resp. (high): (3)

Shock, Dehydration, or Too much bld pressure meds

(Reasons for abnml) BP (low): (3)

HTN or pain

(Reasons for abnml) BP (high): (2)

160

BP High: treat prn @ __ systolic

pain

5th VS:

False, pt determines acceptable level; NOT us

T/F The pt DOESN'T determine acceptable levels of pain, but medical employees DO.

location, intensity, & characteristics of pain

JACHO standards/ presence of pain: (3)

OLD CARTS
Onset; Location; Duration
Characteristics; Aggravating/Alleviating Factors; Radiation; Timing; & Severity (1-10)

Assessing Pain: (8)

ABC: Airway, Breathing, Circulation

pt Prioritization: (3)

True

T/F Anything a NU delegates, they ARE responsible for even though someone else is performing the task.

Assesses & Teaches

(Regarding delegation) The NU best __ & __

Physical Exam

Complete 1st thing after VS

10

A physical exam should last __ min

Failure to report pt changes

# 1 reason why NU are sued:

Neurological (A&O x 3)(PERRLA)(EENT)
Upper Resp. (lung sounds)
CV/Apical Pulse (APETM)
GI (inspection, auscultation; palpation)(Q's)
GU (palpate & Q's)
CV upper extremities (skin turger/breakdown/bilateral pulses/ cap refill)
CV Lower extremities (bilateral pulses/edema/cap refill/ skin)
Posterior Resp. (lung sound/Axilliary line for RML)
Skin & Equipment
Pain
CC

List Order for PA: (11)

Teaching a pt, Assessment of a pt, & Evaluation of a pt

Items that can NOT be delegated: (3)

pt & feelings (how do you feel this pain is affecting your life?

Therapeutic communication: (2)

Report

Must get a __ before assessing a pt

Medical, Surgical, CC

Pt History: (3)

CC

_ _ is why the pt came in to get help

Chest pain; Chest pressure; (if yes) Radiation; SOB; N/V; Diaphoresis (sweating); & get ALL 5 Heart sounds

MI focus on these Q's/signs: (7)

Diaphragm & intercostals

2 muscles to help you breathe

down; expands

Breath = diaphragm goes __; exhale = __

Right Pleural Space (rgt lung)
Left Pleural space (left lung)
Mediastinum (over sternal boarder/ where Heart is)

Three major spaces of the chest:

Base; Apex (dif from heart)

__ = bottom of lung
__ = top of lung

Axillary line

RML is aka __ __

2 left; 3 rgt (RML - Axillary line)

5 Lobes total for the lungs: __ left & __ right (...)

1-7
8-10
11-12

Bone Structure for Ribs:
_-_ = attached
_-_ = join
_-_ = free/ floating

Media Sternum, Pleural spaces, Scapula (no lung sounds)...

Framework of Thorax (3)

Analaxusis

gas exchange

Alveoli

__ is the small sac in lungs where gas exchange takes place (Analaxusis)

Bronchus --> Bronchioles --> Alveolar Ducts --> Alveoli

__ --> __ --> __ --> Alveoli

Right; Left

(Right/Left) main stem bronchus is larger & more vertical the the (Right/Left)

Right main stem bronchus

Main place for Aspiration

Aspiration

aka choking

Carina

__ is before the break off & it's where we want the ETT (endo-tracheal tube) placed

2-3 cm above the Carina

the rgt main stem bronchus is about _-_ cm above the ___

Semi-Fowlers

Place pts in ___ position if they have dif. breathing

Symmetry of Chest movement
Flailing Chest = Asymmetrical
Using Accessory Muscles? Common w/ asthema (chest & abdominal)
Children = Retraction (areas of chest sunken in)
Absence or use of accessory muscles
Inspecting Resp. Rate (12-20) count w/ pulse
Chest Wall shape (pigeon or barrel chest)
Color of lips and nail beds = circulation
Increase in anterior-posterior diameter (transverse measurement)

Inspection of Chest; Things to remember: 9

No, bc they depress the CNS
Rate, Depth, & Regularity

(yes/no) Give Narcotics if less than 12 respirations/min?

Pigeon & Barrel chested

two abnml chest conditions:

Cyanotic

__ = blue color (no oxygen) = result of poor circulation

Transverse measurement; greater

__ measurement should be larger than anterior --> posterior. Anterior should measure __ in distance than if ou did anterior to posterior.

COPD

condition seen w/ COPD & Chronic Asthma

Crepitus

When air has escaped from the lungs and gotten into the subcutaneous tissue (can get in joints too) (sounds like rice crispies)

Neumothorax

Lung collapses (need chest tube to expand lung again)

Tactile fremitus

Ulnar part of hand on their back and have them repeat 99 over and over again...(want vibrations to be equal); This is done to check and see if there is any fluid in the lungs

Trachea Placement;
Attention Neumothorax

__ __ = should be midline (tip head back to check)
Deviated to rgt/left if not midline
This is a result from __ ___ = Lung Collapses on its own, so air moves to compensate for other side

Adventisious

__ Lung Sounds = abnml lung sound

Rhonchi

__ Sound in lungs = UPPER airway garbage;
Loud, Low, & Coarse sounding.
Can be Anterior/Posterior(harder to hear)
Can be moved out by a cough or cleared throat (chart even if clears out)
Ask pt to cough. if it clears, then pt has ___

Wheezes

High, Musical pitch sounds
Heard during INSPIRATION/EXPIRATION
Air has difficulty getting through (restriction in air flow)
Sometimes you can hear it audibly
Note Location & if it was Inspiration/expiration
It can be heard everywhere

Crackles

Anml lung sound that sounds like hair being rubbed b/t fingers.
Coarse
Can't be cleared with a cough
Found best at lower posterior area

Pleural Friction Rub

Abnml lung sound: Occurs when inflammation of lung rubs against each other
Heard in the LOWER anterior part

Atelectasis

Incomplete expansion or collapse of alveoli caused by hypoventilation
Pain
Lungs won't fully expand

Atelectasis

__ S&S: Diminished breath sounds
Won't hear much of anything
Low-grade temp (alveoli doesn't expand, so body tries to fight an infection that isn't there.
Decrease oxgen saturation
Coming back from surgery (need to get them breathing) incentive spiromometer

Diminished breath sounds
Won't hear much of anything
Low-grade temp (alveoli doesn't expand, so body tries to fight an infection that isn't there.
Decrease oxgen saturation
Coming back from surgery (need to get them breathing) incentive spiromometer

S&S of Atelactasis (5)

Position our pts so they can breath better so they can expand lungs (chair/high fowlers, orthopic)
Make pt take deep breaths and cough (if not they will hypoventilate)
Ambulation - walking around
Splint incision (ie hold pillow when coughing)

Prevention for Atelatasis: (4)

Cheyne-Stokes

Bradypnea - Slower than 12 breaths/ min - __ __ = Varying periods of increased depth interspersed with apnea (speeds up; slows down; no breathing)

Kussmaul

Tachypnea - Faster than 20 breaths/ min - __ = Rapid, deep, & labored (metabolic Acidosis) (decreased pH is Acidic) (Renal failure: Diabetics)

Hyperpnea

AKA Hyperventilation

Pleural Space

__ __ surrounds lung

Mediastinum

__ holds heart

Ask pt to take a DEEP breath in (if pain gets worse...it can possibly be respiratory in nature).

How to Differentiate Chest Pain:

Atelectasis

incomplete expansion or collapse of alveoli caused by hyperventilation
Diminished breath sounds
low grade tem
decrease oxygen sat
Improvement of temp with incentive spirometer use (NU intervention)

Position: Sit upright
Sit in chair
Ambulate
Cough & deep breathe
Incentive Spirometer
Medicate to prevent Hypoventilation

Nursing intervention (6)

Chronic Obstructive Pulmonary disease; Emphysema

COPD = ? = AKA __

COPD/ Emphysema/ Chronic Bronchitis

Irreversible expiratory airflow obstruction
Causes over inflation
Breathing all this in, but not getting it all out
Hyperinflation of Alveoli (barrel chested/transverse measurement)
Can see on Chest Xray

Diminished breath sounds (bc alveoli are still inflated during inspiration)
SOB or Excertional Dyspnea
A-P diameter exceeds transverse
Clubbed nail beds (shamroth test - put nail beds together and nails don't meet)
Will hear A LOT of wheezing
CO2 levels are always HIGH
Your bodies CO2 level tells your body to breathe
Chest Xray shows hyperinflation
You can kill a pt if you give them to much oxygen!!! (bc your taking away their drive to breathe. Need lower levels of CO2)

PA for COPD/Emphysema/ Chronic Bronchitis (9)

Transverse Measurement

True Sign of COPD

Nml driven by blowing off CO2,
Changes to low level of oxygen in COPD pt
Nml only give 3L of oxygen for COPD pts

Stimulus to Breathe: (3)

3 Liters

only give __ of oxygen for COPD pts

Pneumonia;
Yellow = Staph
Green = Pseudomonas;
Infiltrates: associated w/ pneumonia

Inflammatory response of bronchioles and alveolar spaces (bacterial, fungal, or viral)
Productive Cough Sputum Color: Yellow = __; Green = __.
Hear Crackles
Dyspnea & Tachypnea
Fever: 101.1
Chest wall pain (take deep breath)
Chest xray will show ______.

Bronchitis

Inflammation of the bronchial Tubes (UPPER airway infection)
Rhonchi - Upper airway garbage
Wheezes
Cough (may or ay not be productive) (We want them to cough it up)
Fever
can turn into pneumonia
SOB

Pneumothorax

Blunt force
Partial collapse of the pleural cavity. Presence of positive air in the pleural space
SOB
Diminished to absent breath sounds
Cuanosis (bluish color)
Tachycardia
Tracheal deviation to unaffected side
Subcutaneous emphysema AKA Crepitis

Crepitis

AKA Subcutaneous Emphysema

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