NU 215-4: Physical Assessment
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Created by:
Vitalized88 on October 10, 2010
Subjects:
Description:
Pcc Nursing
Physical Assessment
Teacher: Miss Scott
2010-Fall
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134 terms
Terms | Definitions |
|---|---|
 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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