Physical Assessment

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Author:
saraherin
ID:
201508
Filename:
Physical Assessment
Updated:
2013-02-19 18:42:16
Tags:
Nursing Process
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Description:
SCF Level I
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  1. Techniques of physical assessment:
    • Inspection
    • Palpation
    • Percussion
    • Auscultation
  2. Aspects of inspection include:
    • lighting
    • look for size, shape, color, symmetry, position, and abnormality.
    • check for symmetry 
    • Validate findings with patient
  3. Aspects of palpation:
    • start with light - move to deep 
    • use differing parts of the hand to detect different characteristics.
  4. What can percussion help you to determine?
    size and density of structures
  5. During auscultation what portion of the stethoscope would you use for low sounds?
    Bell for low 

    murmurs or carotid artery
  6. What is a bruit?
    pronounced "brew-ee' - abnormal sound made by blood flowing through a narrowed artery
  7. General survey entails:
    assessment of: appearance, vial signs, height & weight

    • Grooming
    • personal care 
    • breathe smell
  8. Skin assessment entails what techniques?
    inspection & palpation
  9. What details are included in a skin assessment?
    Color: pigmentation and color

    • Moisture 
    • Temperature
    • Texture 
    • Turgor / hydration
  10. Cyanosis =
    bluing of the skin, may indicate low oxygenation
  11. Jaundice =
    Yellowing of the skin or sclera, may indicate poor kidney function
  12. Erythema =
    Redness, may indicate circulation changes.

    Can be seen in the scrum, heels, hips
  13. What does ABCD stand for when using in skin assessment?
    • Asymmetry
    • Border irregularity 
    • Color 
    • Diameter
  14. Where and how would you assess for edema?
    ankles, instep, calf

    palpate to determine mobility, consistency, and tenderness.
  15. Turgor refers to:
    elasticity of the skin.

    edema or dehydration may affect turgor
  16. Hearing is associated with which cranial nerve?
    • 8th  
    • vestibulocochlear nerve - 
    • inner ear to the brain - balance
  17. Hearing acuity can be tested by what 3 methods?
    • Whisper
    • Rinne 
    • Weber
  18. What is ototoxicity?
    injury to the auditory nerve due to antibiotic use
  19. What should a healthy tympanic membrane look like?
    pearly gray  / cone of light
  20. Describe a normal bronchovesicular sound:
    blowing, medium in pitch, medium intensity, inspiratory is equal to expiratory
  21. Where is best to hear bronchovesicular sounds?
    anterior over bronchioles, lateral to the sternum at intercostal spaces 1 and 2

    posterior between scapulae
  22. What side of the stethoscope would you use to listen to a child?
    bell
  23. Normal Vesicular sounds can be described as :
    soft, breezy, and low pitched.

    Inspiration lasts 3 X longer than expiration
  24. Rails or crackles can indicate what in the lungs?
    random, sudden re-inflation of aveoli - fluid 

    may be cleared with coughing
  25. Rhonchi may indicate what in the lungs?
    Fluid, mucus in the larger airways
  26. Wheeze  heard in the lungs may indicate what?
    narrowed airways due to inflammation
  27. Where would you assess  PMI?
    Point of Maximal Impulse

    intercostal space 5 - medial to the midclavicular line
  28. Closing of the bicuspid or mitral valve is called what?
    S1
  29. At what location would you hear the closure of the tricuspid valve?
    • Apex - this would be S1 or "lub" 
    • 5th intercostal space
  30. When the aortic and pulmonic valves close, what do you hear?
    "dub" or S2
  31. What heart sound can you hear at the Left ICS 2 ?
    Pulmonic valve

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