Term
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Definition
"general survey"
systemic, deliberate critical observations.
Concentrated "watching"
Begins the 1st moment you meet w patient
Use senses-sight,smell,touch,hearing
Always the first step in physical assessment |
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Term
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Definition
Purpose-use of touch
Determines texture, size, consistency, and location of body parts |
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Term
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Definition
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Term
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Definition
| detect surface characteristics;accustom patient to being touched (~1/2 inch deep) |
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Term
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Definition
best use for abdominal contents
(1-2 inches) |
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Term
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Definition
Fingertips-use for fine tactile discrimination
Finger-Thumb Opposition-use for position,shape, consistency of an organ/mass
Dorsa of hands/fingers-use for temp
Metacarpophalangeal joints or ulnar side of hand-use for vibration |
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Term
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Definition
| Purpose-assess location,size, and density of underlying structures |
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Term
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Definition
the art of striking one object against another to create sound
Non-dominant hand-middle finger placed firmly on area to be percussed,fingers seperated
Striker hand: makes a striking force;sharp downward wrist motion; tip of middle finger strikes joint of middle finger on non dominant hand |
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Term
| 5 percussion notes and characteristics |
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Definition
1. Tympany
2. Resonant
3. Hyper resonant
4. Dull
5. Flat |
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Term
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Definition
Intensity-loud
Pitch-high
quality-drumlike
location-stomach intestine |
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Term
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Definition
Intensity-med-loud
Pitch-low
Quality-hollow
Location-normal lung |
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Term
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Definition
Intensity-louder
Pitch-lower
Quality-booming
Location-adult lungs increased air (COPD) |
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Term
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Definition
Intensity-soft
Pitch-hihg
Quality-muffled thud
Location-liver,spleen |
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Term
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Definition
Intensity-very soft
Pitch-high
Quality-dead stop
Location-thigh,bones,tumor |
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Term
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Definition
Intensity-very soft
Pitch-high
Quality-dead stop
Location-thigh,bones,tumor |
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Term
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Definition
| Purpose-listening to sounds produced by the body using a stethoscope |
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Term
| 4 characteristics of sound |
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Definition
| Pitch,quality, loudness, duration |
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Term
| Fit and quality of stethoscope |
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Definition
| earpiece slope points forward toward your nose |
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Term
| Diaphragm and Bell Endpieces |
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Definition
Diaphragm-flat edge for high pitched sounds-ex-breath,bowel,and normal heart sounds
Bell-hollow cuplike for low pitched sounds-ex-extra heart sounds, murmurs or bruits |
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Term
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Definition
Eliminate confusing artifacts
ex-noisy room,hairy chest>carackles; your breathing on tubing
Never listen thru a gown/clothing
Exam Room-warm, comfortable, quiet, private, well lit, no distractions/noises
Exam table-Position so both sides of patient are easily accessible |
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Term
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Definition
Platform scale with height attachment
Sphygmomanometer
Stethoscope
Thermometer
Flashlight/Penlight
Tuning fork/reflex hammer
Tongue depressor
Vision screener (index card)
Flexible tape measure and ruler
Sharp object (for pain sensation)
Cotton balls (for light touch) |
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Term
| Equipment and a safe environment |
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Definition
-CLEAN GLOVES
-clean the equipment
-clean vs used area for handling equipment
-Nosocomial infections
-wash hands
-standard precautions
-transmission based precautions |
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Term
| Standard Precautions: use with all |
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Definition
-Wash Hands:after touching body fluids, whether or not wearing gloves
-Wash Hands: after removing gloves
-Wash Hands: between each patient
-Wear Gloves: when touching body fluids
-Changes gloves between tasks
-Remove gloves promptly after each use and before touching non contaminated objects
-Wear mask and eye protection if expecting "splashes" |
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Term
| Your approach to doing a Phys Assesment |
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Definition
Consider:
-Patient's emotional state
-Examiner's emotional state
Hands on: where to start
-Measure Ht/Wt and vital signs
familiar, non threatening actions
-Begin with person's hands
skin color, nailbeds, metacarpophalangeal joints
-Concentration on one step at a time
stepsmay differ with age of patient
Organize your step so patient doesnt have to change positions too often |
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Term
| Physical Assessment, continued.... |
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Definition
-Examination sequence
may write out exam sequence and refer to it as you proceed
-Brief health teaching
do this as you proceed through the exam
-When findings are complicated
may want to linger longer to concentrate on some finding
"Just because i'm lingering a long time doesnt mean that anything is wrong with u"
-Summarize findings for person |
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Term
EYES
Structure and Function: External Eye
External Anatomy |
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Definition
Palpebral fissure
Canthus
Conjuctiva
Lacrimal Apparatus
Extraocular muscles |
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Term
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Definition
| eliptical open space between eyelids |
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Term
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Definition
| corner of eye; angle where lids meet |
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Term
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Definition
| thin mucous membrane; transparent protective covering of eyeball and mucous membrane |
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Term
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Definition
| constant irrigation to conjuctiva and cornea |
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Term
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Definition
| (#6) give eye straight and rotary movement |
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Term
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Definition
Outer layer
Middle layer
Retina |
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Term
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Definition
sclera: fibrous protective white covering
cornea: covers iris and pupil |
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Term
| Middle layer(choroid layer) |
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Definition
Iris varies opening by adjusting pupil size; contract in bright light and accomodate for near vision; dilate pupil when light is dim and for far vision
Pupil i sround and regular |
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Term
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Definition
visual receptive layer in which light waves are changed into nerve impulses
Optic disc- area in which retinal fibers converge to form optic nerve
Macula- on temporal side of the fundus; recieves & transduces light from the center of the visual field |
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Term
Visual Reflexes:
1. Pupillary light reflex
2. Fixation
3. Accomodation |
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Definition
1. normal consriction of pupils when bright light shines on retina: no conscious control of it
A. Direct light reflex: when bright light exposed to one eye
B. Consensual light reflex: simultaneous constriction of other pupil
2. a reflex directing eye towards an object attracting that persons attention: impaired by drugs,alcohol, fatigue
3. Convergence of the axes of the eyeballs with constriction of the pupils; adapts eyes for near vision |
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Term
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Definition
Arcus senilis-degenerative lipid material infiltrates the cornea
Presbyopia-lens ability to change shape to accomodate near vision(lost elasticity,becomes hard,glasslike)~40yr
Nuclear sclerosis-or sensile cataract-transparent fibers of lens become thick and yellow~70 yr
Floaters in Vitreous-from debris accumulation
Night driving affected-adaption to darkness so need more light to see |
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Term
| Most common causes of decreased visual functioning |
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Definition
1. Cataract formation or lens opacity(~46% of 75-85 yr olds)
2. Glaucoma-increased intraocular pressure(~7% 75-85;M>F)
3. Macular degeneration-or loss of central vision=blindness(28% 75-86yr) |
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Term
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Definition
-vision difficulty(decreased acuity,blurring,blind spots)
-Pain
-strabismus(deviation of A-P axis of eye)
-Diplopia(perception of 2 images of a single object)
-Redness,swelling
-watering,discharge
-past history of ocular problems
-glaucoma(increased intraocular pressure)high BP to eyeball
-Use of glasses or contacts
-Self care behaviors |
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Term
| Additional subjective data (eye) for aging adult |
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Definition
-? vision difficulty climbing stairs or night driving
-? last vision test for glaucoma, pain around eyes, loss of peripheral vision
-? history of cataracts; loss or progressive blurring
-? Do eyes feel dry or burning; decreased tear production, decreased elasticity
-? Decrease`in usual activities
ex. reading, sewing
central vision acuity lost w/ macular degeneration |
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Term
Objective data(eye)
Physical exam |
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Definition
1. Test central vision acuity(snellen eye chart) and near vision (handheld vision screener)
Note: hesitancy, squinting, leaning forward, misleading letters
2. Test visual fields
-Confrontation test
-gross measure of peripheral vision-CNII
-compare pt.'s peripheral vision to examiner(assuring its normal)
HOW: Cover pt.'s eye and opposite eye of examiner
2 ft away using pencil or finger
slowly advance it in from periphery
ask person to say "now" when sees it |
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Term
| Continued objective date eye |
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Definition
3. Corneal light reflex(hirschberg test)
Assesses parallel alignment of eye axes by shining light towards persons eye.
HOW: have pt. stare straight ahead
hold light~ 12 inches away
shine a light towards persons eyes
Normal: reflection on cornea should be in exactly the same spot on each eye
Abnormal: asymmetry of the light reflex: deviation in alignment due to eye muscle weakness or paralysis
-If it is deviated the muscle in the eye has been affected |
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Term
| objective data continued eye |
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Definition
4. Diagnostic positions test
Lead eyes through 6 cardinal positions of gaze-CN II,IV,VI
HOW: follow movement of your finger with only their eyes
hold finger 12 inches away
Normal: parallel tracking of object with both eyes
Abnormal: nystagmus: a fine oscillating movement seen-iris |
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Term
| objective data continued eye |
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Definition
5. Inspect external ocular structures
eyebrows, eyelids, lashes, eyeballs,(moist and glossy
6. Inspect anterior eyeball structures
Conjuctiva-normal: clean and pink over lower lid and white over the sclera
Sclera-normal: china white; gray blue or muddy in dark skinned
Cornea-normal: smooth,clear, and no irregulation
Iris-normal: flat w/ round regular shape
Pupils-normal: round,regular, equal size
Abnormal: anisocoria: unequal size pupils, 5% people |
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Term
| Objective date continued...eye |
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Definition
7. Test for PERRLA
Pupils,Equal,Round,Reactto Light,Accomodate |
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Term
| How to do PERRLA test: 3 steps |
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Definition
1. Inspect both for round and equal
2. Pupillary light reflex
-advance light in from each side forward from ear
Normal: constriction of pupils when bright light shines on retina
3. Accomodation
HoW: have person focus on distant object; should see pupils dilate. Then have person shift gaze to near object-your finger held 3 inches from nose
Normal: see both pupils constrict and both eyes axes converge |
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Term
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Definition
1. external ear(auricle or pinna)
2. Middle ear (air filled cavity inside temporal bone)
3. Inner ear (sensory organs for equilibrium and hearing) |
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Term
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Definition
funnels sound waves
-External auditory canal: opening into exrernal ear
Cerumen: yellow waxy material; lubes and protects T.M.
Tympanic Membrane(eardrum): pearly gray color, seperates external ear from middle |
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Term
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Definition
-contains auditory ossicles:malleus,incus, and shape
-Eustachian tube-connects mid ear to nasopharnyx:allows air passage during swallowing and yawning |
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Term
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Definition
-Contains bony labyrinth: inside is vestibule and semicircular canals, and cochlea(central hearing apparatus)
looks like snail |
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Term
Eustachian Tube
Instillation of ear drops in Adult and child >3?
Instillation of ear drop in child <3? |
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Definition
adult-pull pinna up and out
child<3-pull pinna down and back |
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Term
Hearing
Auditory system has 3 levels |
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Definition
1. Peripheral-ears transmit sounds and convert vibrations into electrical impulses
Organ of Corti-receptor hair cell fibers
2. Brainstem: locates direction of the sound in space
3. Cerebral cortex: interprets meaning of the sound ex. stroke pt.s-cant interpret the meaning of the sound
The normal pathway of hearing is: air conduction
Less efficient is bone conduction |
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Term
Hearing Loss
(obstruction of sound transmission)
3 types |
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Definition
1. Conductive:mechanical dysfunction of ex-or mid ear. can hear sound if amplitude is increased. obstruction from foreign body, perforated T.M., impacted cerumen
2. Sensorineural-pathology of inner ear,CN VIII. increased amplitude doesnt help;cause presbycuss: cause gradual nerve degeneration(aging)-and or ototoxic Rx which destroy hair cells in cochlea
3. Equilibrium: inner ear labyrinth signals brain about bodys position. inflammation sends wrong info=vertigo: staggering gait and a strong,spinning, whirling sensation |
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Term
| Ototoxic hearing loss from RX |
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Definition
-NSAIDs-aspirin,indomethacin,naproxen
-aminoglycosides-streptomycin,gentamycin,neomycin
-loop diuretics-lasix,edecrin
-antimalarials-quinine,chloroquine
-vancomycin |
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Term
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Definition
ear canal-course and thick
cerumen drier-appocrine gland atrophy
impacted cerumen-common but reversible hearing loss
history of frequent infections >eardrum scarring
ex. people that listen to incredibly loud music/sounds, rock bands |
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Term
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Definition
-earache
-infections
-discharge
-hearing loss
-environmental noise
-tinnitus(ringing,crackling,buzzing)
-vertigo
-self care behaviors |
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Term
| Obj data-physical exam of ear |
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Definition
Prep:
-position
cleaning ear canal
Inspect external ear
-for position and alignment
-for skin condition
-patency of external auditory meatus
Palpate external ear
-for tenderness-palpate auricles and push tragus,palpate mastoid process |
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Term
physical exam of ear
Test hearing acuity |
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Definition
Whisper voice whisper test-CN VIII
How: one finger on tragus
1-2 ft from persons occluded ear
exhale and whisper a 2 syllabus word
(tuesday, armchair, baseball, fourteen)
Normal: person should repeat word correctly |
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Term
| Thorax and Lungs: surface landmarks |
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Definition
Thoracic Cage-bony, conical shape
contains sternum, 12 pair ribs, 12 thoracic vertebrae, diaphragm |
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Term
| Anterior thoracic landmarks |
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Definition
Suprasternal notch
Sternum
Manubriosternal angle |
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Term
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Definition
| U shape, above sternum, in b/w clavicles |
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Term
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Definition
| 3 parts:manubrium,body, xiphoid process |
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Term
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Definition
"Angle of Louis"
articulation of the manubrium and body of sternum
this is where you start counting ribs
-Also, it is the site of tracheal bifurction into R&L bronchi and upper border of atria of heart |
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Term
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Definition
| where R&L costal margins meet at xiphoid |
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Term
| Posterior Thoracic Landmarks |
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Definition
Vertebra prominces-spinous process of C7
Spinous processes are knots of vertebrae |
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Term
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Definition
| C1-7, T1-12, L1-5, S5(fused) |
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Term
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Definition
| where ribs join cartilage |
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Term
| Inferior angle of scapula(lower tip) |
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Definition
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Term
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Definition
| Midway between spine and persons side |
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Term
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Definition
used to pinpoint a finding vertically on chest
For example: on anterior chest |
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Term
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Definition
| bisects thorax at sternum |
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Term
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Definition
| bisects clavicle at midpoint b/w sternoclavicular joint and acromioclavicular joint |
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Term
| Structure-Thoracic cavity |
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Definition
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Term
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Definition
| middle of thoracic cavity; contains esophagus, trachea, heart, and great vessels |
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Term
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Definition
| Anterior, lateral, and posterior |
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Term
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Definition
| apex is 3-4 cm above inner 1/3 clavicles; base rests on diaphragm at 6th rib, midclavicular line |
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Term
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Definition
| from apex of axilla to 7-8th rib |
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Term
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Definition
| C7=apex of lung tissue-and-T10=base |
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Term
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Definition
paired but not symmetrical
Right is shorter than left (liver)
Left is narrower than right (heart bulges left)
Right has 3 lobes
Left has 2 lobes stacked on the diagonal |
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Term
| Anterior structure of lobes |
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Definition
| apex of lung is 3-4cm above inner third of clavicle |
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Term
| Posterior structure of lobes |
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Definition
| contains almost all lower lobe |
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Term
| Lateral structure of lobes |
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Definition
| extends from apex of axilla to 7-8th rib |
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Term
| What beginning examiners need to know: |
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Definition
1. left lung has no middle lobe
2. Anterior chest contains mostly upper and middle lobes with very little lower lobes
3. posterior chest contains almost all lower lobe |
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Term
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Definition
Visceral pleura line outside of lung
Parietal pleura lines outside of chest wall and diaphragm |
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Term
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Definition
| a vaccumm; negative pressure(hold lungs tight against chest wall); filled with few ml of lube fluid (so during respiration, lungs slide up and down noiselessly) |
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Term
| Trachae and bronchial tree |
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Definition
Trachea: lies anterior to esophagus; is 10-11cm(adult); extends from cricoid cartilage to Angle of Louis
Bronchi-transport gases b/w environs and lungs |
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Term
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Definition
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Term
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Definition
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Term
| Respiratory starts in your? |
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Definition
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Term
Mechanisms of Respiration
4 functions of respiratory system |
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Definition
Supply O2
Remove CO2
Establish homeostasis/acid-base balance
maintain heat exchange |
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Term
| What controls respiration |
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Definition
| the normal stimulus to breath is an increase of carbon dioxide in the blood |
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Term
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Definition
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Term
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Definition
| decrease of oxygen in blood |
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Term
During respiration, chest size changes
Inspiration?
Expiration |
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Definition
Inspiration- vertical(top to bottom) diameter lenghtens with downward movement of diaphragm: so, anterior-posterior diameter increases
Expiration-vertical diameter shortens with upward movement if diaphragm; so Anterior to posterior diameter decreases |
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Term
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Definition
-costal cartilages calcify-less mobility to thorax
-respiratory muscle strength decrease starting-50
-decrease in elastic properties within lungs
-harder for the lungs to inflate with each respiration
-results in small airway closure
-so have a decrease vital capacity and increase residual volume |
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Term
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Definition
-Vital capacity
-Residual volume
-#of alveoli decrease so less surface area for gas exchnge
-lung bases becomes less ventilated since closing a number of airways so therefore an increase risk of dyspnea with exertion beyond person's usual workload
Also older persons risk of postoperative complications increase especially atelectasis and infection from decreased ability to cough, loss of protective airway secretions, and increased secretions |
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Term
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Definition
| the maximum amount of air that a person can expel from the lungs after first filling the lungs to maximum |
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Term
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Definition
| the amount of air remaining in the lungs even after the most forceful respiration |
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Term
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Definition
| partial or total collapse of lung usually from a bronchus obstruction of bronchus ventilating a segment of lung tissue |
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Term
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Definition
-cough
-SOB
-chest pain with breathing
-past history of resp infections
-smoking history
-environmental exposure
-self care behaviors
-additional ?s for aging adult(fatigue with normal ADLs, sob) |
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Term
| Paraoxysmal nocturnal dyspnea |
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Definition
| cant breathe when they lay down |
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Term
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Definition
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Term
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Definition
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Term
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Definition
Prep:
-Position and draping
-timing during a complete exam-start in back
-cleaning stethoscope end piece
Equipment needed:
-stethoscope
-small ruler marked in cm
-alcohol wipe(clean stethoscope) |
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Term
Physical Exam
Posterior Chest-Inspect
Thoracic Cage |
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Definition
Shape and configuration
-spinous process straight line
-thorax is symmetric,elliptical shape
-downward sloping ribs @45 deg re:spine
-Scapulae symmetrical in each hemithorax
(skeletal deformities limit excursion:kyphosis,scoliosis) |
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Term
Posterior Chest-Inspect
Anteroposterior |
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Definition
transverse diameter: 1:2 to 5:7
If A-P diameter=transverse diameter > barrel chest |
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Term
| Note: position of person needed when breathing |
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Definition
Tripod position if COPD give leverage to aid in expiration
Note skin color and condition
For example: blue=cyanotic |
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Term
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Definition
Symmetric expansion
Tactile(or vocal) fremitus
Palpate entire chest wall |
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Term
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Definition
warm hands with thumbs at T9 or T10
slide hand medially to pinch
have person breath
On inhalation, thumbs should move apart ymmetrically |
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Term
| Tactile (or vocal) fremitus |
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Definition
-a palpable vibration
Use palmer base of fingers or ulnar side of hand
Start over lung apices and palpate from one side to other
Have person say 99 or blue moon
Assess for bilateral symmetry of vibrations felt |
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Term
| Palpate entire chest wall |
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Definition
| for tenderness, temp,moisture, lumps, masses |
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Term
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Definition
coarse crackling sensation palpable over skin surface
(when air escapes from lung and enters SQ tissue) |
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Term
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Definition
| to assess predominant note over lungs fields |
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Term
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Definition
| predominant note over healthy adult lung fields;low pitch, clear hollow sound |
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Term
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Definition
when too much air is present;
Ex. emphysema or pneumothorax or child: low pitched, booming sounds |
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Term
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Definition
signals abnormal density
Ex. when very muscualar or increased SQ fat/obese and pneumonia; plueral effusion, atelectasis, tumors; soft, muffled thud |
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Term
| Posterior Chest-Auscultate |
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Definition
breath sounds:
characteric noises heard through chest wall as air passes through tracheo-bronchial tree |
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Term
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Definition
Position person sitting, leaning forward slightly, and instruct to breath through mouth
Consider background noises vs lung sounds
1. stand behind person and start
2. Auscultate posterior start from apices (~C7) to bases (T10)
3. Auscultate lateral from axilla down to 7-8th rib
4. Use zigzag sequence
5. Listen for one full respiration at each site
6. Always compare RIGHT side to LEFT |
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Term
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Definition
Bronchial (tracheal) breath sounds
Bronchovesicular breath sounds(mixed sounds)
Vesicular breath sounds |
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Term
| Broncial(tracheal) breath sounds |
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Definition
-harsh hollow sound
-high pitch, low amplitude, inspir =expir,
-best heard(anteriorly):over trachea and larynx |
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Term
| Bronchoveslcular breath sounds |
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Definition
-mixed sounds
-mod pitch, mod amplitude, inspir < expir
-best heard anteriorly over major bronchi, near sternum in 1st & 2nd ICS
-heard pasteriorly: between scapula especially on right |
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Term
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Definition
-rustling(wind) sound
-low pitch,soft amplitude, inspir > expir
-best heard (posteriorrly) over perpheral lung field |
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Term
| Adventitious (abnormal) lung sounds |
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Definition
Wheeze
crackles
rhonchi
friction rub
stridor |
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Term
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Definition
musical whistling sound
Expira > Inspira
from narrowed airways
(resulting from bronchoconstriction or secretion) |
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Term
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Definition
crackling sound;at end of Inspiration;
resulting from collapsed or waterlogged alveoli |
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Term
| Rhonchi(moist coarse rales) |
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Definition
bubbling sound; Inspira >Expir;
Resulting from air bubbling past secretions in airways |
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Term
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Definition
creaking leathery sound; end of Inspir and begin of Expir;
resulting from rubbing of inflamed pleural surfaces |
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Term
|
Definition
upper airway obstruction
(larynx or trachea) from swollen, inflammed tissue or lodged foreign body |
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Term
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Definition
shape and configuration of chest wall
facial expression
level of consciousness
skin color and condition; lips and nail beds
quality of respirations |
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Term
| Anterior Chest-palpate for tenderness, lumps, masses |
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Definition
-Symmetric chest expansion
How:
Place hands on anterolateral wall with thuimbs along costal margin and pointint toward xiphoid process
Have pt. take deep breath
Watch thumbs move apart symmetrically and note smooth expansion of chest with your fingers |
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Term
Anterior chest-palpate
Tactile fremitus |
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Definition
-palpate over lungs apices in supraclavicular area
-compare vibrations from one side to other when pt says "99"
-avoid palpating over female breast |
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Term
|
Definition
Begin in apices of supraclavicular area
Percuss in intercostal spaces, comparing side to side
Expected Percussion notes:
-resonance in supraclavicular areas and RUL,RML,LUL
-Flat, over muscle or bone
-Dull over heart(L) and liver(R) and female breast
-Tympany-over stomach |
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Term
| Auscultate Posterior Chest |
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Definition
while standing behind patient:
Auscultate from the apices at C7 to the bases(~T10) and laterally from the axilla down to the 7-8th rib |
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Term
| Auscultate Anterior Chest |
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Definition
While standing in front of the patient:
Auscultate from the apices in supraclavicular area down to 6th rib
Listen for one FULL respiration at each site, always comparing sides (right and left) |
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Term
| Measuring Pulmonary Function Status |
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Definition
Forced expiratory time
Pulse Oximeter
6-minute distance walk |
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Term
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Definition
Number of second to exhale from total lung capacity to residual volume. Measures air flow obstruction
HOW:
Take a deep breath;blow it all out hard with open mouth; Listen over sternum; normal time for full expiration is 4 secs of less |
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Term
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Definition
Noninvasive measure to assess arterial oxygen saturation
Normal 97-8% |
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Term
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Definition
-Simple measure of functional status in aging adults; mirrors real life conditions
HOW:
Locate a flat walk surface; low traffic; comfortable shoes; pulse ox on
-Instruct to walk at own pace; cover as much ground as possible in 6 minutes; sit or rest periods ok
Normal: walking > 300 meters in 6 mins= persons more likely to angage in ADLs |
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Term
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Definition
1. Chest configuration change from increased A-P diameter (round barrel shape) Kyphosis(outward curvature of thoracic spine)
2. Bony prominence of thoracic cage from decreased SQ fat
3. Chest expansion decreased (but should be symmetrical)
4. Fatigues easily with deep mouth breathing (during auscultation) avoid hyperventilation |
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Term
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Definition
| outward curvature of thoracic spine |
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Term
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Definition
barrel chest
kyphosis
lordosis |
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Term
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Definition
Tachypnea
Bradypnea
Hyperventilation
Hypoventilation
Cheyne-stokes respiration
Biot's respiration
Chronic obstructive pulmonary breathing(COPB) |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| irregular shallow pattern |
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Term
| Cheyne stokes respiration |
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Definition
| cycle of wax(increased rate and depth) and wane |
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Term
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Definition
| Cheyne stokes but irregular |
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Term
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Definition
| normal inspiration and prolonged expiration |
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