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Terms in this set (215)
What is Edema?
Where do you pinch to assess turgor?
Back of forearm or sternum
How do you check for vascularity?
Push into skin and see if it blanches
Temperature is best assessed using the _________ portion of the hand
Where to look for pallor?
Nails, nail beds, and lips
Best place to check for cyanosis?
What is erythema?
Redness of the skin
Types of Edema:
-due to inflammation/injury
Used to predict patients at risk for skin breakdown
Braden Scale score range
Lower the score, greater risk
Largest organ in the body
Lesions are measure in
Flat, non-palpable, change in skin color, smaller than 1cm
Example of a macule
Elevated solid mass, deeper and firmer than papule 1-2 cm
Example of a nodule
solid mass that extends deep through subcutaneous tissue, larder than 1-2cm
Example of tumor
irregularly shaped, elevated area or superficial localized edema, varies in size
Example of wheal
Hive, mosquito bite
circumscribed elevation of skin filled with serous fluid, smaller than 1cm
Example of vesicle
herpes simplex, chickenpox
Most common skin abnormality
Basal cell carcinoma
What does the A stand for in the skin ABCD assessment
What does the B stand for in the skin ABCD assessment
What does the C stand for in the skin ABCD assessment
What does the D stand for in the skin ABCD assessment
Circumscribed elevation of skin similar to vesicle but filled with pus, varies in size
Example of pustule
Acne, staphylococcal infection
Deep loss of skin surface that extends to dermis and frequently bleeds and scars, varies in size
Example of ulcer
venous stasis ulcer
Thinning of skin with loss of normal skin furrow, with skin appearing shiny and translucent; varies in size
Example of atrophy
a discoloration of the skin resulting from bleeding underneath, typically causes bruising
a solid swelling of clotted blood within the tissues; goose egg, blood underneath
Normal nailed degree
Normal cap refill time
Farsightedness. Can see distant objects but not close ones
Near sightedness. Can see close but not distant objects
Impaired near vision at middle age and older adults caused by loss of elasticity of the lens
Congenital- both eyes do not focus on an object simultaneously; cross eyed
Increased capacity of the lens
Intraocular structural damage from elevated intraocular pressure; leads to blindness
Define macular degeneration
Damaging sharp and central vision. Wet and dry. Wet blood vessels from under the macula. Dry occurs when the macula thins causing blurring and eventually blindness
P in PERRLA
E in PERRLA
First R in PERRLA
Second R in PERRLA
A in PERRLA
Pupils, Equal, Round, Reactive to Light, Accommodation
Define whisper test
Patient should hear you 1-2 feet away
Define Rinne test
Air conduction greater than bone conduction 2:1
Define Weber test
Sound heard equally both ears
How to asses the lymph nodes
-palpate with pads of fingers
-palpate both sides simultaneously
-normal: non palpable, non tender
1st focused assessment:
When assessing two of anything....
Assess at the same time
Two parts of an assessment:
Define subjective data
Symptoms; what the patient says, opinion
Define objective date
Signs; what is assessed, labs, tests
RN must assess their patient every _____ hours
Define screening exam
Community setting or in doctor's office
Define health maintenance
Follow up for previously treated condition, or chronic illness
Define annual exams
More comprehensive than focused; mammograms
Define focused exam
Used for acute illness, more detailed, will ALWAYS include assessment of heart and lungs
Types of physical exams
Low pitched, hollow, heard over normal lung tissue
Flat or extremely dull sound:
Dull or thud like sound:
Dense areas like heart and liver; when fluid or solid tissue replaces air containing lungs
Hyper resonant sound:
Louder, lower pitched than resonant; children chests or thin adults or pneumothoraxic
Hollow, drum like, over stomach; indicates excessive air
Bananas and avocados contain
How deep is light palpation?
1/2 inch deep
How deep is deep palpation?
2 inch deep
The bell of the stethoscope is for _______ pitch sounds, so press __________
Use the bell to hear
Unexpected heart sounds, bruits
The diaphragm of the stethoscope is for _______ pitch sounds, so press ________
Use the diaphragm to hear
heart sounds, bowel sounds, lung sounds
Auscultation is used to hear
lung, bowel, and heart sounds; + bruits
created by turbulence in major arteries due to blockages of increased vasculature such as enlarged thyroid; carotid artery
Position to asses head, neck, back, thorax and lungs, breasts, axillae, heart, vital signs, and upper extremities
Position to asses head, neck, thorax and lungs, breasts, axillae, heart, abdomen, pulse sites
Position to assess head, neck, thorax and lungs, breasts, axillae, heart and abdomen, best to assess abdomen
Position to assess female genitalia
Position to assess rectum and vagina
Position to assess musculoskeletal system, assess hip and knee extension of hip joint
Position to assess recctum
Low Fowlers position
Semi Fowlers position
High Fowlers position
Major source of energy
Maintains the health and mobility of the large intestines
Needed for growth, development, maintenance, and repair
Makes essential hormones and enzymes
Transports and stores fat soluble vitamjns
Provide structure for cell membranes and cushioning for internal organs
Simply put, starches and sugars
Examples of monounsaturated fats
Olive oil, canola oil, peanut oil, avocados, peanut butter almonds
Examples of polyunsaturated fats
Soybean oil, sunflower oil, walnuts, flaxseed, sunflower seeds, fish
Examples of saturated fats
Meats, lards, butter, cheese, dairy products, palm oil and coconut oil
Examples of trans fat
"Partially hydrogenated oils"; commonly found in fried foods and shelf food
Found in carrots, sweet potatoes, spinach, broccoli, egg yolks
Helps vision keeping eyes, mouth, skin, & lungs moist
Deficiency results in night blindness, dry skin/nails, acne, ridges on nails
What is the primary purpose of a physical exam?
If the patient is seriously ill, what do you asses first?
The body system that is most at risk
When do you perform painful assessments?
At the end
Symptoms that guide your data collection more efficiently
Patient culture who wish for no blood to be drawn
Culture that doesn't make eye contact and even thinks it is rude
What could smelling a fruity, sweet smell be linked to
What do you palpate the skin for?
Vibration is best felt using
Palmar or ulnar surface of the entire hand and the base of the fingers
The finger tips are sensitive to
pulsation, position, texture, size and consistency
Rules of palpation
Start with light palpation, be systematic, calm and gentle
Proceed to deep palpation if necessary.
Is tactile fremitus normal or abnormal?
What is tactile fremitus?
Tactile fremitus are vibrations that are felt by hand on the chest wall, tested by having pt say "ninety nine"
How to listen to lungs?
With diaphragm, press firmly
3x longer than exhalation
Vibration on "99" vocalization is
Equal and stronger at the top
Soft, breezy, and low pitched. Inspiratory phase is 3x longer than exploratory
Vesicular breath sounds
Where can you best hear vesicular breath sounds?
Periphery of lung, except over scapula
Vesicular breath sound origin
Created by air moving through smaller airways
Blowing sounds that are medium pitched and intensity. Inspiratory phase equal to expiratory phase
Bronchovesicular breath sounds
Where can you best hear bronchovesicular breath sounds?
Posteriorly between scapulae and anteriorly over bronchioles lateral to sternum and first and second ICS
Bronchiovesicular breath sound origin
Created by air moving through large airways
Loud, and high pitched with hollow quality. Expiration lasts longer than inspiration (3:2)
Bronchial breath sounds
Where can you best hear bronchial breath sounds?
Bronchial breath sound origin
Created by air moving through trachea close to chest wall
Alveoli collapse, deflation, high pitched
Continuous, low pitched
High pitched, whistle, continuous, nasal flaring
Pleural friction rub
If apical pulse is <60 BPM during certain medication administration, what do you do?
When assessing heart, what should you ask first?
Heart health history
Where is the Point of Maximal Impulse located?
5th intercostal space, left mid-clavicular line
The bottom region of the heart is called what?
What valves close to cause S1?
Mitral and Tricuspid
What calves close to cause S2?
Aortic and Pulmonic
What happens if you feel both carotid arteries at the same time?
Rule with recording blood pressure
Always record highest blood presses reading
Distended blue neck vein when laying that doesn't go away when sitting up. Normal/abnormal?
What pulse would you check if your pt has a heart cath?
Absent, not palpable (Doppler)
Pulse diminished, barely palpable (weak)
Full pulse, increased (too much fluid)
Check thumb side of wrist for which pulse
Check little finger side of wrist for what pulse
pump blood out
Pumps blood in
What is phlebitis?
Inflammation of the vein
pain, pulse, pallor, paresthesia, paralysis
Common area for cancer in breast
Tail of spence
Maybe be a cancerous cyst if
No pain, no movement
Abdomen assessment order
When auscultating the abdomen, listen to
What organs are found in the upper right quadrant of the stomach?
Liver and gallbladder
What organs are found in the upper left quadrant of the stomach?
Spleen and pancreas
What organs are found in the lower left quadrant?
What organs are found in the lower right quadrant?
What is peristalsis?
Movement inside the abdomen
Which side of the stethoscope would you use to listen to the heart and arteries? Vascular sounds
What does Hypertonicity mean?
Increased resistance with any sudden passive movement of a joint
What does Hypotonicity mean?
Muscle feels flabby
What does atrophy mean?
What does muscle cast mean?
One muscle much stronger than muscle on opposite side
Decreasing angle between two bones
Increasing angle between two bones
Movement of body part beyond its normal resting extended position
Movement of body part beyond its ventral surface faces downward
Movement of body part so front or ventral surface faces upward
Movement of extremity away from midline of body
Movement of extremity toward midline of body
Rotation of joint inward
Rotation of join outward
Turning body part away from midline
Turning body part away from midline
Flexion of toes and foot upward
Bending of toes and foot downward
The Glascow Coma Scale rates the level of what?
Pt can't express thoughts, but understand what they want to say
Pt can't express thought and does not understand
How do you test a pt's C7 facial nerve?
Smile, raise eyebrows, wrinkle eyebrows
Used for Pt's with a stroke
What 3 things do you always assess?
Heart, lungs, abdomen
3 types of assessments and order?
1. General Assessment; across the room
2. Focused Assessmentl why the pt is there
3. Full Assessment; head to toe
Fist percussion helps
assess for tenderness over the kidneys, liver and gallbladder
Amplitude or intensity
(loud or soft)
Pitch or frequency
(high or low)
What does CAGE mean?
Ever feel the need to Cut down on your drinking?
Do you get Annoyed by people criticizing you?
Do you feel Guilty about drinking?
Have you ever used a drink as an Eye opener or to make you feel normal?
Assessed signs that indicate oxygenation problems
Reduced mental alertness, nasal flaring, somnolence, and cyanosis
continuous sounds caused by muscular spasm, fluid, or mucus in larger airways; or new growth or external pressure causing turbulence. Best heard over bronchial tree
Rhonchi are low-pitched
high-pitched continuous musical sounds or whistling sound like a squeak heard continuously during inspiration or expiration. They usually are louder on expiration and often are heard in asthma. Heard in bronchial tree
dry, rubbing or grating quality and is caused by inflamed pleura: parietal pleura rubbing against visceral pleura. High pitched
pleural friction rub
best heard over the periphery of the lung. They are breezy and low pitched
vesicular breath sounds
blowing sounds best heard between scapulae and anteriorly over bronchioles lateral to the sternum
Bronchovesicular breath sounds
The point of maximum impulse is located at the
4th - 5th ICS just left of the midclavicular line.
What is a thrill?
Continuous palpable sensation that resembles the purring of a cat.
Use the ________ of the stethoscope and listen for low-pitched extra heart sounds such as S3 and S4 gallops, clicks, and rubs.
Brown pigmentation around ankles and edema are examples of __________ insufficiency
Pale color, cool extremities, decreased for absent pulse, thin shiny skin with decreased hair growth and thickened nails are examples of ________ insufficiency
superficial veins that become dilated, especially when the legs are in a dependent position
Dependent edema around the area of the feet and ankles is a sign of
venous insufficiency or right-sided heart failure`
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