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acute

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begins abruptly with marked intensity of sever signs and symptoms and then subsides after a period of treatment

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assessment

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evaluation or appraisal of the patients condition

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borborygmi

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loud, gurgling sounds that accompany increased motility of the bowel.

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bruits

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abnormal swishing sounds heard over organs, glands and arteries.

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chronic

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developing slowly and persisting for a long period of time

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crackles

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short, discrete, interrupted crackling or bubbling breath sound, most commonly heard upon inspiration

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disease

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any disturbance of a structure or function of the body; a pathologic condition of the body

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drainage

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passive or active removal of fluids from a body cavity, wound or other source of discharge by one or more methods

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dullness

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low-pitched, thud like sounds

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edema

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swelling

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erythema

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redness

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etiology

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the cause of the disease

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exudate

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fluid, cells, or other substances that are slowly discharged from cells or blood vessels through pores or breaks in the cells membrane (ex: perspiration, pus)

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flatness

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soft, high-pitched, flat sound

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focused assessment

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concentration of attention on the part of the body where signs and symptoms are localized

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functional disease

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may be manifested as an organic disease, but fails to reveal evidence of structural or physiologic abnormalities (nervous or mental disease)

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infection

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caused by an invasion of microorganisms that produce tissue damage (bacteria, viruses, fungi)

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inflammation

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protective response of body tissues to irritation, injury, or invasion of organisms (redness, swelling, heat)

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inspection

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purposeful observation

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level of consciousness

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patients level of orientation to person, place, time and purpose

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neoplastic

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abnormal growth of tissues (cancer)

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nursing health history

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-The initial step in assessment process data collected about the patients level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness -Biographical Data: -date of birth, sex, address, family memers, marital status, religious preference, occupations, source of health care, and insurance.

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nursing physical assessment

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identification by nurse of the needs, preferences, and abilities of the patient -The purpose is to determine the patient's state of health or illness -Initial step of the nursing process and in forming the nursing care plan When to perform a physical assessment: -Perform assessment as soon after admission as possible -Initial assessment is done by RN -ongoing assessment is the responsibility of the LPN and RN

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objective data

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data observed by the nurse such as behavior and collective data

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organic disease

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results in a structure change in an organ that interferes with its functioning (stroke)

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palpation

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feels the texture, size, consistency and location off certain parts of the body with the hands

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percussion

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use of fingertips to tap the body's surface to produce vibration and sound

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pruritus

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itching

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purulent

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producing or containing pus

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remission

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a partial or complete disappearance off clinical and subjective characteristics of a disease

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signs

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objective data as perceived by the examiner

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subjective data

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symptoms; verbal statements provided by the patient

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symptoms

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subjective data; indications of illness that the patient perceives

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thrill

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fine vibration sensation along the artery, which is palpated

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turgor

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the normal resiliency of the skin

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tympany

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high-pitched, drum like sound

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wheezes

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breath sounds that have a whistling or sighing sound

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Risk factors for Disease

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Genetic and Physiologic, Age, Environment, Lifestyle

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Hereditary Disease

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transmitted genetically from parents to children

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Congenital Disease

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appear at birth or shortly thereafter but are not caused by genetic abnormalities

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Inflammatory Disease

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Those in which the body react with an inflammatory response to some causative agent.

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Degenerative Disease

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implies degeneration, often progressive

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Infectious Disease

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result from the invasion of microorganisms int the body

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Deficiency Disease

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result from the lack of a specific nutrient

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Metabolic Disease

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caused by a dysfunction that results in a loss of metabolic control of homeostasis in the body. (diabetes)

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Traumatic Condition

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result from both physical and emotional trauma

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Environmental Disease

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develop from exposure to a harmful substance in the environment

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Autoimmune Responses

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body develops immunoglobuins (antibodies) against it's own tissues or body substances

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Risk Factor

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Any situation, habit, environmental condition, genetic predisposition, physiologic condition, or other variable that increases the risk of an individual or group to illness or accident

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Cardinal Signs of Infection and Inflammation

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erythmea, edema, heat, pain, purulent drainage, loss of function

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Sitting Position

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Assesses head and neck, back, posterior thorax and lunges, anterior thorax and lungs, breasts, axillae, heart, vital signs and upper extremities

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Supine Position

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Assess head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen, extremities, pulses

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Dorsal Recumbent Position

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Assess head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen

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Lithotomy Position

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Assess female genitalia and genital tract

question

Sims' Position

answer

assess rectum and vagina

question

Prone Position

answer

assess Musculoskeletal system

question

Lateral recumbent Position

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assess heart

question

Knee-chest Position

answer

assess rectum

question

Physical Assessment Techniques

answer

Inspection, Auscultation, Palpation, Percussion

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Chief Complaint

answer

patients subjective reason for obtaining health care

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ABC, in-out, PS

answer

Airway, Breathing, Circulation, what's going in?, what's going out?, Pain, Safety

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Pitting Edema Scale

answer

1+ : trace - barely perceptible pit 2+ : mild - a deeper pit with fairly normal contours; rebounds in 10-15 seconds 3+ : moderate - a deep pit; lasts for 30 seconds to more than 1 minute 4+ : severe - even deeper pit; sever edema that possibly lasts as long as 2 - 5 minutes

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First step in Nursing Process

answer

Assessment: -Systematic collection -Verification -Organization -Interpretation -Documentation of Data

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Auscultation

answer

The process of listening to sounds produced .by the body

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Sources of Data

answer

Primary: Client or major provider of information about client Secondary: Sources of data other than client (family members, other health care providers, medical records.

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Types of Data

answer

Objective: -Observable -Measurable -Obtained through physical examination and lab and diagnostic testing Subjective: -Symptoms from client's point of view -Perceptions, feelings and concerns -Collected by interview

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Signs and Symptoms

answer

Disease and Diagnosis Disease: -Disturbance of a structure or function -Recognized by a set of signs and symptoms -Signs and symptoms are clustered in groups to make a medical diagnosis -Assessment of signs and symptoms to formulate a nursing diagnosis

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Origins of Disease

answer

Disease of illness originates from many causes: heredity, congenital, inflammatory, degenerative, infectious, deficiency, metabolic, neoplastic, traumatic, and environmental -Unknown etiology -Disease that have no apparent cause

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Risk Factors for Development of Disease

answer

A risk factor is any situation, habit, environmental condition, genetic predisposition, physiologic condition, and other that increases the vulnerability of an individual or a group to illness or accident -Risk factors do not necessarily mean that a person will develop a disease condition, only that the chances or disease are increased -Categories of risk factors (genetic and physiologic, age, environment, and lifestyle)

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Terms used to describe disease

answer

Chronic: Develops slowly and persists over a long period, often for a person's lifetime Remission: Partial or complete disappearance of clinical and subjective characteristics or a disease Acute: Begins abruptly and marked with intensity of severe signs and symptoms and then often subsides after a period of treatment. Organic Disease: Results in structural change in an organ that interferes with its functioning Functional Disease: May be manifested as organic disease, but careful examination fails to reveal evidence of structural or physiologic abnormalities

question

Medical Assessment

answer

-Physical examination is conducted by the physician -The nurse is often expected to carry out certain functions Functions expected of the nurse: -Preparing the exam room -Assisting with equipment -Preparing the patient -Collecting specimens

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Nursing Assessment

answer

Initiating the Nurse-Patient Relationship -The first interview is the most challenging to conduct -Introduce yourself and state name, position, and purpose of the interview -Give estimate of time -Ask if the patient has any questions and answer them appropriately -Communicate trust and confidentiality -Convey competence and professionalism

question

The interview for the Nursing Assessment

answer

-Provide relaxed, unhurried manner -Conduct in a quiet, private, well lighted setting -Convey feelings or compassion and concern -Determine by what name the patient wishes to be addressed -Nurse should have an accepting posture, relaxed eye level, and pleasant facial expression.

question

Reasons for Seeking Health Care

answer

Chief Complaint -Documentation information in patient's own words The nurse can use the OPQRSTUV method: -O Onset timing, onset duration -P provocative/palliative -Q quality/quantity -R region/radiation -S severity -T treatments -U understanding (what do you think is causing it) -V values (goals or care)

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Present Illness or Health Concerns

answer

progression of the present illness from the onset of the current signs and symptoms

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Past Health History

answer

-Previous hospitalizations -Allergies -Habits and lifestyle patterns -Ability to perform ADLs -Patterns of sleep, exercise, and nutrition

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Family History

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-Immediate and blood relatives -Includes health and cause of death, as well as history of illness -Objective is to determine patient's risk for illnesses of a genetic or familial nature -Provides information about family structure, interaction and function

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Review of Symptoms

answer

-systematic method for collecting data on all body systems -record in clear and concise manner with appropriate terminology -ask specific questions relating to functioning of each system.

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Where to perform a Nursing Assessment

answer

-comfortable, private setting -In most cases, the patients own room works well and is convenient

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Methods of Nursing Physical Assessment

answer

-Head-to-toe -System-by-system -Focused

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Performing the Nursing Physical Assessment

answer

-Items needed: penlight, stethoscope, blood pressure cuff, thermometer, gloves and tongue blade -nurse also makes use of the senses of touch, smell, sight and hearing -Always wash your hands before beginning assessment

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Head-to-toe Assessment Neurologic

answer

-Level of consciousness (Alert, lethargic, stuporous, obtunded, comatose) -Level of orientation (X1-person, X2-place, X3-date and time, X4- purpose) = A&O x 4 -Hand grips -Paralysis -Weakness

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Head-to-toe Skin and hair

answer

-observe skin for color, temperature, moisture, texture, turgor and evidence of injury or skin lesions -Note color of sclera, mucous membranes, tongue, lips, nail beds, palms and soles -Determine the quantity, quality, and distribution of hair -hair should be smooth, not oily or dry -scalp should be free of dandruff, lesions, or parasites

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Head-to-toe Head and neck

answer

-Note facial expression -Note symmetry of features -Assess arteries, veins, and lymph nodes -Palpate beneath the jaw and down each side of the neck to feel for enlarged lymph nodes -Palpate carotid arteries -Assess jugular vein distention -Auscultate the carotid carotids for bruits (clicking sound)

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Head-to-toe Mouth and Throat

answer

-Inspect the lips and mucous membranes with tongue blade and penlight -Note condition of teeth and gums -Note breath odor

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Head-to-toe Eyes

answer

-Note symmetry -Assess for exudates -Assess sclera -Observe pupillary reflex

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Head-to-toe Ears

answer

-Note symmetry -Assess ear canal -Note ability to hear and follow commands -Note use of hearing aids if applicable

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Head-to-toe Nose

answer

-It should be symmetrical -Assess patency (openness) -Observe for bleeding or drainage -Assess nares

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Head-to-toe Chest, lungs and heart and vascular system, Breasts

answer

-inspect for bilateral chest expansion -note rate and rhythm of respirations -breathing should be QUIET -note posture -Examine and encourage monthly breast self-exams Lung sounds: -Instruct patient to breath through mouth quietly and more deeply and slowly that a usual respiration -place stethoscope firmly but not tightly on the skin and listen for one full respiratory/expiratory cycle at each point -systematically auscultate using a zig-zag pattern

question

6 P's of Dyspnea

answer

-pulmonary bronchial constriction -pneumo-thorax -possible foreign body -pulmonary embolus -pneumonia -pulmonary embolus

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Sibilant wheezes

answer

have a high pitched squeaking musical quality and are produced by airflow through narrowed airways

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Sonorous wheezes

answer

have a lower-pitched, courser, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and the large airways

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Stridor

answer

High pitched, inspiratory crowing sound, louder in the neck than over the chest wall. Originates in the larynx or trachea, and indicates upper airway obstruction from edematous, inflamed tissues or a foreign body

question

Pleural Friction rubs

answer

produced by inflammation of the pleural sac, you will hear a rubbing grating, or squeaky sound upon auscultation. Sounds like two pieces of leather rubbing together.

question

Suggested sequence for systematic percussion and auscultation of the thorax

answer

1. posterior thorax 2. Right lateral thorax 3. Left lateral thorax 4. Anterior thorax

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Head-to-toe spine

answer

Spine: -note the curvature while in a sitting and standing position Heart sounds: -Auscultate with stethoscope -Listen for intensity of the sound, faint - strong -Determine the regularity of the rhythm -Listen for 60 seconds

question

5 areas for listening to the heart

answer

1. Aortic 2.Pulmonic (left 2nd intercostal space 3. Erb's point (S1 and S2 Left 3rd intercostal space) 4. Tricuspid (lower left sternal border, 4th intercostal) 5. Mitral (left 5th intercostal, medial to midclavicular line)

question

Head-to-toe Peripheral vascular system

answer

-palpitate peripheral pulses -rate the strength on a 0 - 4+ scale (pg 71) -Assess extremities for symmetry, color and varicosities -Asses temperature of hands and feet -Perform capillary refill or blanch test

question

Circulation assessment 5Ps

answer

-Pain -Pulse -Pallor -Paresthesia (tingling?) -Paralysis

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Head-to-toe abdomen

answer

-inspect for shape, contour, lesions, scars, lumps, or rashes -Auscultate for bowel sounds in all quadrants -Perform palpation and percussion

question

Head-to-toe Genitourinary system

answer

-inspect labia/genitalia and pubic hair -Palpate the scrotum -Palpate the suprapubic area

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Head-to-toe Rectum

answer

-spread buttocks and assess for hemorrhoids or lesions

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Head-to-toe legs and feet

answer

-palpate femoral, dorsalis, popliteal and posterior tibial pulses -Observe and palpate for edema (pg 117) -Test for range of motion -Check color, motion, sensation, and temperature of both feet

question

Pulse Volume Variations

answer

0 Absent Pulse: None felt 1+ Thready Pulse: Difficult to feel, not palpable when only slight pressure is applied 2+ Weak Pulse: Somewhat stronger than a thready pulse but not palpable when light pressure is applied 3+ Normal Pulse: Easily felt but not palpable when moderate pressure is applied 4+ Bounding pulse: Feels full and springlike even under moderate pressure

question

PERRLA - pupillary reflex test

answer

Pupils Equal Round Reactive Light Accommodation

Foundations of Nursing V.6 – Ch 5 Physical Assessment – Flashcards

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