Study sets, textbooks, questions
Upgrade to remove ads
Arts and Humanities
HA Lab: Module 3 Phys. Assessment of Adult- Terminology, Equipment & Integument ATI
Terms in this set (104)
What is the intent of physical assessment?
To collect, validate, interpret, and document accurate information you find when conducting a physical exam.
T/F: Physical assessment can be complete, incorporating multiple body systems, or focal- limited to examining specific body systems.
Assessment is always __________ meaning that it reflects the patient's status at a specific point in time.
Describe the following part of the integument assessment:
Inspect the skin systematically from head to toe for color, color variation (and their impacts on potential diagnoses), hair distribution, and lesions.
Skin color- do you note blue coloration/cyanosis? Yellow/jaundiced from liver disease?
Inconsistent color- patchiness, places lacking pigment, could be vitiligo or skin cancer
Hair distribution- excess facial hair, adequate body hair distribution
Look for bruising or other injuries- sign of neglect
What is the integument?
Hair, skin, and nails
Describe the following part of the integument assessment:
Inspect and palpate the hair for quantity, texture, distribution, color, and parasites.
Starting with patient's head and scalp, inspect skin for color, hair distribution, and an lesions. Be sure to inspect for the presence of infestation such as lice or nits. Inspect all of the person's skin, uncovering one body part at a time.
Describe the following part of the integument assessment: Palpate and inspect the skin head to toe for temperature, texture, and moisture. How do we do this? What are we looking for in temperature?
As you inspect, palpate the skin as well. Note its texture and moisture using fingertips and temperature using back of your hand. Temp should be consistent from trunk to extremities.
Texture & moisture may vary due to cultural or developmental differences. How does the skin of older adults compare? How about darker-skinned people?
Skin of older adults tends to be thin and dry.
Skin of those with high levels of melanin (darker skin) tends to be thicker.
An increase in skin temperature in one particular area denotes..
inflammation or infection
A decrease in skin temperature in one particular area denotes...
decreased blood flow or decreased tissue perfusion
Describe the following part of the integument assessment: Palpate the skin overall for skin turgor, edema, and lesions. How do we know if patient is hydrated?
Over patient's clavicle, pinch skin fold gently to check skin turgor, which reflects hydration status.
Well-hydrated skin over clavicle is resilient and returns quickly to its original shape. Poorly hydrated skin retains "pinched" shape.
What is turgor and what does it reflect in the body?
Skin turgor is measurement of skin's elasticity- looks at hydration status.
Well-hydrated skin is more elastic, while dehydrated skin will retain pinched shape when turgor is tested.
Why is body-hair distribution on the lower legs of clinical significance?
Patients with peripheral vascular disease are often hairless below midcalf area of their legs due to lack of bloodflow.
Hairlessness can be an indicator of poor blood flow in general.
How do we evaluate patients for edema? How do we document our findings?
Check the lower extremities for edema by pressing part of the skin or ankle. If you leave a thumbprint, or dent, in the skin surface, then you must document that edema is present and how far up the leg it continues, as well as how the other leg compares (edema there also?).
Clinical significance of unilateral edema is what? What should we do if we see unilateral edema?
Swelling of one extremity over the other can indicate inflammation, venous thromboembolism, or lymphedema.
Measure the affected extremity and observe for additional signs like erythema and tenderness.
redness of the skin caused by congestion of the capillaries in the lower layers of the skin is called...
Describe how to perform the following aspect of the integument assessment: Inspect and palpate the nails for color, shape, thickness, adhesion to the nailbed, lesions, clubbing, and capillary refill.
Inspect nails of both feet and hands looking at color and shape- nail should be firmly attached. Look for signs of fungal infection or clubbing. Press gently over nail to cause blanching and look for capillary refill.
What does a fungal infection of the nails look like?
Thickening in nails, yellowing, and ragged nail edges
What does clubbing of the nails look like?
Clubbing is an enlargement of the fingertips and flattening of the angle between the fingernail and the nailbed.
How do we assess nails for capillary refill? What is a normal result and what is abnormal?
Gently press over nail to cause blanching. Normally pink color will return to nail within 2-3 seconds. Delayed capillary refill greater than 3 seconds indicates decreased tissue perfusion.
T/F: Delays in capillary refill as seen in nail test (gently pressing to cause blanching) may be normal in older adults and those with chronic illnesses.
Explain how to examine all skin on posterior surface of the body for integument assessment. What do we pay attention to? What 3 signs do we look for?
Inspect the skin over all posterior surfaces- especially bony prominences.
1. skin softening (esp. on heels)
3. open areas
For posterior body surface assessment- what areas do you need to pay special attention to for patients on bed rest?
Bony prominences such as elbows, coccyx, hips, and heels
What is the danger to a patient in a wheelchair's integument?
They may experience skin breakdown over their ischial tuberosities at the lower edge of their buttocks.
What should you do if you find any areas of redness (erythema) on posterior side of patient's body? How do you know if skin has been damaged by pressure?
Press lightly with your finger to see if skin blanches or lightens with pressure. Nonblanchable erythema indicates it has been damaged by pressure.
______________ is a classic sign of long-term oxygen deprivation found in integument assessment.
__________ is an adjustment, especially that of the lens of the eye for various distances, manifested by the contraction of ciliary muscles and other changes.
_________ is the external expression of emotion attached to thoughts, mood, and ideas
__________ is a fluid or blood-filled sac formed by the dilation of the wall of an artery.
_________ is the absence of the sense of smell.
____________ in nursing is the portion of the nursing process that includes collecting, verifying, and analyzing data to develop a patient's plan of care
___________ is listening for sounds within the body, usually with a stethoscope.
__________ are long, low-pitched hollow sounds normally heard over the trachea.k
bronchial breath sounds
____________ are medium-pitched and quieter sounds normally heard over the mainstem bronchi
bronchovesicular breath sounds
__________ are blowing or swishing sounds heard in an artery that indicate turbulence of blood flow.
________ is enlargement of the fingertips and flattening of the angle between fingernail and nailbed, a classic sign of oxygen deprivation.
__________ is relating to all aspects and processes of perceiving, thinking, and remembering
___________ is the delicate membrane that lines the eyelids and covers the exposed surface of the sclera.
Plural of conjunctiva
The ___________ is the part of the conjunctiva that covers the cornea and front part of the sclera, appearing white because of sclera behind it.
The ________ is the portion of the conjunctiva lining the eyelids, appearing red because of the blood vessels/vascularity.
_________ is a dry, crackling, or grating sound or feeling produced by air in subcutaneous tissue or by bone rubbing on bone.
________ means furthest from the origin of a part.
_________ is an accumulation of excess interstitial fluid, usually in the subcutaneous tissues.
___________ is redness of the skin produced by capillary congestion.
_________________ are a set of six muscles innervated by the cranial nerves that move the eyes in a conjugate (parallel) manner.
The extraocular muscles are tested by a number of physical examination techniques including the ______________ and ____________.
6 cardinal positions of gaze, corneal light reflex test.
___________ is any material such as fluid, cells, or cellular debris that has escaped from blood vessels and has been deposited in tissues/ on tissue surfaces usually as a result of inflammation
______ is with a local or centralized focus.
_________ is a scratching or squeaking sound that is heard over the lung fields or the precordium, indicating inflammation of the pleural or the pericardial lining.
A friction rub, scratching/squeaking sound heard over lung fields or precordium indicates ________ or ____________.
inflammation of the pleurae or pericardium
____________ is the gum, the part of the oral mucosa that overlies the crowns of unerupted teeth and encircles the necks of those that have emerged.
Plural of gingiva (gum)
____________ is the protrusion of a loop or portion of an organ or tissue through an abnormal opening in a muscle wall, palpated as a mass or lump on the skin.
__________ is a covering, such as the skin, hair, and nails.
The _______ is a large protuberance on the inferior part of the posterior margin of the body of the ischium, the three major bones that make up each half of the pelvis.
______________ is the muscle that closes the mouth and is the major muscle involved in chewing/mastication.
__________ is excessive convex curvature of the thoracic spine. what population is this common in?
Kyphosis- elderly adults
A _______ is a single, untwisted synthetic filament (as of nylon).
___________ is a blowing or whooshing sound heard on ausculation of the precordium, signifies turbulent blood flow of the heart caused by valvular defect
__________ is one of the external orifices of the nose. ______ is the plural version.
The _______ is the skin crevice between the nose and the corner of the mouth
_____________ is rapid, repetitive, involuntary and rhythmic movement of the eyeball
__________ is an instrument used to inspect the ears
_________ is paleness; a decrease or absence of skin coloration.
___________ is the longitudinal opening between the eyeballs.
___________ is open or unobstructed.
____________ is the waves of contraction that propel contents through the gastrointestinal tract.
__________ is pertaining to the sole of the foot.
_________ is an accumulation of air or gas in the pleural space.
____________ is the region of the anterior surface of the body covering the heart and stomach, comprising the epigastric region and inferior part of thorax.
__________ means nearest to the origin of a part
__________ means pertaining to motor effects caused by cerebral activity
_________ is drooping of the upper eyelid
__________ means containing pus
___________ are discontinuous sounds heard primarily during inhalation, resulting primarily from air bubbling through moisture in alveoli or from collapsed alveoli popping open, also called crackles.
__________ is pain that increases when pressure (as from a hand) is removed.
__________ is backward flowing of blood through the orificies of the heart valves due to abnormal closing of the valves.
___________ are dry, low-pitched, snore-like noises produced in the throat or bronchial tube due to a partial obstruction such as secretions.
_________ means shaped like a boat or having a concave appearance
_______ is the tough white outer coat of the eyeball
_________ is an appreciable lateral deviation in the normally straight vertical line of the spine.
_____________ is a dividing wall or partition, this one is the structure that separates the two nares.
A ________ is an instrument that exposes the interior of a passage.
___________ is an abnormal narrowing of a duct, canal, or blood vessel.
The _________________ is one of two muscles arising from the sternum and the inner part of the clavicle and inserting at the mastoid process. It rotates and laterally flexes the neck.
____________ is a harsh, high-pitched breath sound such as that heard on inhalation with an acute laryngeal obstruction.
_______________ is placing the heel of one foot in front of and touching the toes of the other foot and repeating the process to walk in a straight line, used as a test of gait and sobriety.
_____________ is a source of illumination directed from an angle to the side of what is being examined- used to make a raised lesion cast a shadow, for example.
___________ means pertaining to the lateral region of the head
_____________ is a muscle that arises in the temporal fossa and inserts into the lower jaw and closes the jaw.
_________ means chest.
__________ is a sensation of vibration felt on palpation, such as over the heart during loud, harsh cardiac murmurs.
___________ is a posture that uses three points of support, typically used by patients with pulmonary problems as they lean forward, use their arms for support, and lift the chest to increase breathing capacity.
____________ means pertaining to the ulna, the larger of the two bones in the forearm on the side opposite that of the thumb.
___________ is a general term in anatomical terminology for a pendent, fleshy mass, most often used to refer to the one hanging from the soft palate above the root of the tongue.
_______________ are soft, fine, breezy, low-pitched sounds heard over peripheral lung tissue.
Vesicular breath sounds
___________ is a whistling noise with a high pitch, generated by air flowing through narrowed air passages.
____________ are used to auscultate, or listen to, a variety of sounds generated within the body.
Place the stethoscope earpieces in facing..
To listen to high-pitched sounds, such as heart, lung, or bowel sounds, use the _________ of stethoscope. Gently tap or rub to ensure your stethoscope is rotated correctly.
When listening for low-pitched sounds, such as checking blood vessels for bruits, use the stethoscope's _____________. Use light pressure, but be sure that the entire rubber ring around it is in contact with the patient's skin.
What is a pen light and what are two clinical uses for them?
Use a penlight for better visualization when you examine body orifices, such as the mouth, or in skin folds where you need extra illumination. Penlights are also used to check pupillary responses and to provide tangential lighting when examining skin surfaces.
Two uses for tongue depressors during physical exam
Use a tongue depressor to hold down your patient's tongue while you visualize the throat or to check the gag reflex. Use another tongue depressor for sharp/dull discrimination in the neurologic exam. Simply break it, and then use the half with the sharpest point to test sensation.
Sets found in the same folder
HA Lab: Module 4 Head/Face/Neck/Eyes/Ear…
HA Lab: Physical Assessment of an Adult-…
Pharm Concepts (Ch. 8 Nursing Process)
HA Lecture: Mod. 1 Ch. 2 Cross-Cultural Principles
Sets with similar terms
Nursing fundamentals ch 22 deWit
Foundations in Nursing Quiz 1: Skin, Head, Neck, a…
Skin Health Assessment
Other sets by this creator
FWA Module 1.3: Menstrual Cycle Awareness
FWA Module 1.2- Endocrine System + Hypothalamic-Pi…
GU & Gender Health
Endocrine & Metabolic Disorders