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134 terms

NU 215-4: Physical Assessment

Pcc Nursing Physical Assessment Teacher: Miss Scott 2010-Fall
STUDY
PLAY
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