ch. 34

  1. ventricular gallop
    • S3
    • occurs just after S2
    • premature rush of blood into a ventricle that is stiff or dilated
  2. thrill
    continuous palpable sensation, like the purring of a cat
  3. tactile fremitus
    sounds created by vocal cords, send sound waves, vibrations from waves can be externally papated
  4. ptosis
    abnormal drooping of the lid over the pupil
  5. polyps
    tumorlike growths
  6. nystagmus
    involuntary rhythmical oscillation of the eyes
  7. leukoplakia
    • thick white patches
    • heavy smokers and alcoholics
  8. lordosis
  9. kyphosis
  10. indurated
    hardened, firm
  11. hypertonicity/ hypotonicity
    • increased/decreased tone
    • considerable resistance/hangs loosely
  12. hernias
    protusion of avdominal organs through the muscle wall
  13. exostosis
    bony growth
  14. excoriation
    • skin breakdown
    • redness and skin sloughing
  15. erythema
    • red discoloration
    • indicates circulatory changes
    • due to localized vasodialation
    • sunburn, infalmmation, fever
  16. ectropion/entropion
    eye lid margins that turn out/in
  17. clubbing
    • a bulging of the tissues at the nail base
    • due to insufficient O2
  18. cherry angioma
    ruby red papules
  19. bruit
    a blowing or swishing sound caused by a narrowed section of a blood vessel
  20. whispered pectoriloquy
    certain lung abnormalities cause the whispered voice to become clear and distinct
  21. bronchophony
    • fluid is compressing the lung
    • vibrations from voice are transmitted to chest wall and become clear
  22. borborygmi
    • hyperactive, loud, "growling" sounds
    • indicates increased gastrointestinal motility
  23. atrophied
    • reduced in size
    • feels soft and boggy when palpated
  24. arcus senilis
    • a thin white ring along the margin of the iris
    • abnormal under age 40
  25. 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
  26. 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
  27. eyes
    • pupils- size measured in mm
    • equal
    • round
    • reactive to light
    • accommodation- change in pupil size to adjust vision from far to near
  28. head and neck
    • head
    • eyes
    • nose
    • mouth
    • pharynx
    • neck
    • lymph nodes
    • carotid arteries
    • thyroid gland
    • jugular veins
    • trachea
    • use: inspection, palpatation, ausculation
  29. Nails
    • condition of nails reflects: general health, state of nutrition, occupation, level of self care
    • inspect
    • palpate for capillary refill
  30. hair and scalp
    • assess for type of hair
    • color
    • distribution
    • thickness
    • texture
  31. pustule
    • circumscribed elevation of skin similar to vesicle but filled with pus, varies in size
    • eg acne, staph infection
  32. vesicle
    • circumscribed elevation of skin filled with serous fluid, <1 cm
    • eg chicken pox, herpes simplex
  33. nodule
    • elevated solid mass, deeper and firmer than papule, 1-2cm
    • eg wart
  34. papule
    palpable, circumscribed, solid elevation in skin, <1cm
  35. macule
    • flat, nonpalpable change in skin color, <1cm
    • eg freckle, petechia
  36. skin
    • color
    • moisture
    • temp
    • texture
    • turgor
    • vascularity
    • edema
    • lesions and malignancies
    • macule
    • papule
    • vesicle
    • pustule
  37. general survey
    • assess appearance and behavior
    • assess VS
    • assess height and weight
  38. 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
  39. ausucultation
    • involves listening to sounds
    • requires a good stethoscope
    • requires concentration and practice
  40. percussion
    • tap body with fingertips to produce a vibration
    • sound determines location, size, and density of structures
  41. 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
  42. Inspection
    • uses vision and hearing
    • recognizes normal and abnormal
    • simplest of assessment skills
  43. physical assesment skills
    • inspection
    • palpatation
    • percussion
    • auscultation
    • olfaction
  44. 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
  45. 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)
Card Set
ch. 34