-
ventricular gallop
- S3
- occurs just after S2
- premature rush of blood into a ventricle that is stiff or dilated
-
thrill
continuous palpable sensation, like the purring of a cat
-
tactile fremitus
sounds created by vocal cords, send sound waves, vibrations from waves can be externally papated
-
ptosis
abnormal drooping of the lid over the pupil
-
-
nystagmus
involuntary rhythmical oscillation of the eyes
-
leukoplakia
- thick white patches
- heavy smokers and alcoholics
-
-
-
-
hypertonicity/ hypotonicity
- increased/decreased tone
- considerable resistance/hangs loosely
-
hernias
protusion of avdominal organs through the muscle wall
-
-
excoriation
- skin breakdown
- redness and skin sloughing
-
erythema
- red discoloration
- indicates circulatory changes
- due to localized vasodialation
- sunburn, infalmmation, fever
-
ectropion/entropion
eye lid margins that turn out/in
-
clubbing
- a bulging of the tissues at the nail base
- due to insufficient O2
-
cherry angioma
ruby red papules
-
bruit
a blowing or swishing sound caused by a narrowed section of a blood vessel
-
whispered pectoriloquy
certain lung abnormalities cause the whispered voice to become clear and distinct
-
bronchophony
- fluid is compressing the lung
- vibrations from voice are transmitted to chest wall and become clear
-
borborygmi
- hyperactive, loud, "growling" sounds
- indicates increased gastrointestinal motility
-
atrophied
- reduced in size
- feels soft and boggy when palpated
-
arcus senilis
- a thin white ring along the margin of the iris
- abnormal under age 40
-
Heart
- compare assessment of heart functions with vascular findings
- use inspection and palpation simultaneously
- palpate for PMI
- use auscultation
- locate anatomical landmarks
- identify S1 and S2
-
thorax and lungs
- posterior, lateral, anterior
- identify anatomical landmarks
- use inspection, percussion, auscultation
- most common sounds: vesicular, bronchovesicular, bronchial
- adventitious breath sounds: crackles, rhonchi, wheezes, pleural friction rub
- shap and symmetry
- posture
- equality of movement
-
eyes
- pupils- size measured in mm
- equal
- round
- reactive to light
- accommodation- change in pupil size to adjust vision from far to near
-
head and neck
- head
- eyes
- nose
- mouth
- pharynx
- neck
- lymph nodes
- carotid arteries
- thyroid gland
- jugular veins
- trachea
- use: inspection, palpatation, ausculation
-
Nails
- condition of nails reflects: general health, state of nutrition, occupation, level of self care
- inspect
- palpate for capillary refill
-
hair and scalp
- assess for type of hair
- color
- distribution
- thickness
- texture
-
pustule
- circumscribed elevation of skin similar to vesicle but filled with pus, varies in size
- eg acne, staph infection
-
vesicle
- circumscribed elevation of skin filled with serous fluid, <1 cm
- eg chicken pox, herpes simplex
-
nodule
- elevated solid mass, deeper and firmer than papule, 1-2cm
- eg wart
-
papule
palpable, circumscribed, solid elevation in skin, <1cm
-
macule
- flat, nonpalpable change in skin color, <1cm
- eg freckle, petechia
-
skin
- color
- moisture
- temp
- texture
- turgor
- vascularity
- edema
- lesions and malignancies
- macule
- papule
- vesicle
- pustule
-
general survey
- assess appearance and behavior
- assess VS
- assess height and weight
-
preperation for examination
- infection control
- environment
- equipment
- physical preparation of client
- psychological preparation of client
- assessment of age groups
- assessment of each body system
- follows the nursing history
- systematic and organized
- head to toe approach
-
ausucultation
- involves listening to sounds
- requires a good stethoscope
- requires concentration and practice
-
percussion
- tap body with fingertips to produce a vibration
- sound determines location, size, and density of structures
-
Palpatation
- use hands to touch body parts
- use different parts of hands to distinguish texture, temp and movement
- hands should be warm, fingernails should be short
- start with light and end with deep
-
Inspection
- uses vision and hearing
- recognizes normal and abnormal
- simplest of assessment skills
-
physical assesment skills
- inspection
- palpatation
- percussion
- auscultation
- olfaction
-
positions for examination
- sitting: head, neck, back, posterior thorax and lungs, anterior thorax and lungs, breasts, axillae, heart, vital signs and upper extremities
- supine: head, neck, anterior thorax and lungs, breasts, axillae, heart, abdomen,extremities, pulses
- dorsal recumbent: (supine with legs bent) head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen
- lithotomy: (legs in stirrups) female genitalia and genital tract
- Sims': (on side,stomach,with flexion of hip and knee) rectum and vagina
- prone: musculoskeletal system
- lateral recumbent: (on side) heart
- knee-chest: rectum
-
purposes of physical assessment
- gather baseline data
- supplement, confirm or refute data obtained in the history
- confirm and identify nursing diagnoses (individualize)
- make clinical judgments about a client's changing health status and managment
- evaluate the outcomes of care (aspect of accountability)
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