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Physical Assessment
Test 2 Fundamentals
60
Nursing
09/05/2010

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Cards

Term
Collection of subjective & objective data about the client
Definition
Health Assessment
Term
What the client says it is
Definition
Subjective
Term
What you observe or directly measure. ( can be validated by another)
Definition
Objective
Term
Look at all aspects: physical, psychosocial, spiritual, ( done on initial contact)
Definition
Comprehensive
Term
Conducted at intervols for + or - changes
Definition
ongoing partial
Term
based on clients problem
Definition
focused
Term
This establishes relationship of trust nurse/ client relationship
Definition
Health History Interview
Term
When conducting a health history interview the nurse should do what______
Definition
Use broad questions and watch the clients body language
Term
When establishing the health history what are the esentials
Definition
1. need a quiet private environment
2. Biographical data
3. Reason for seeking care
4. HX of present health concern
5. Medical HX
6. Family HX
7. Lifestyle
Term
What are some instruments used in an assessment
Definition
1. ophthalmoscope
2. otoscope
3.speculums
4. tuning fork
5. percussion hammer
6. snellen chart
7. stethoscope
8. sphygmomanometer
Term
What are some possible positions that may be used in an assessment?
Definition
1. sitting
2. supine
3. dorsal recumbent
4. SIM'S
5. Prone
6. Lithotomy
7. Knee Chest
8. Standing
Term
What are some techniques used for Physical assessment
Definition
1. inspection
2. palpation
3. percussion
4. auscultation
5. use only those techniques that are appropriate to the area being assessed
Term
When performing a general survey what do you need to consider?
Definition
1. General Appearence
2. Vital Signs
3. Height/ Weight
4. Pain
Term
When you are doing the general survey and are looking at General Appearance what are you assessing.
Definition
1. body build
2. Posture
3. hygiene
4. Mood
Term
In the general survey assessing pain what needs to be assessed?
Definition
1. Pain 0-10
2. scale
3. location
4. duration
5. intensity
Term
When inspecting the integument what do you look at or look for?
Definition
1. color
2. vascularity
3. lesions
4. odor
Term
What should the nurse notice when they are palpating the integument?
Definition
1. temp
2. moisture
3. turgor
4. texture
Term
When the nurse inspects the nails what are they looking for?
Definition
1. shape
2. angle
3. texture
4. color
Term
When the nurse is inspecting the hair/ scalp what are they looking for?
Definition
1. Texture
2. Distribution
3. Lumps
4. Lesions
5. Infestations
6. Grooming/ Hygiene
Term
What is the nurse looking for when they are inspecting the skull?
Definition
size and shape
Term
What is the nurse looking at when they are assessing the face?
Definition
symmetry
Term
What is the nurse looking at when they are assessing the eyes?
Definition
1. Symmetry
2. pupil size, shape, response,
Term
What is the nurse looking for when they are inspecting the skull?
Definition
size and shape
Term
What is the nurse inspecting in the face
Definition
Symmetry
Term
What is the nurse looking for when inspecting the eyes?
Definition
1. symmetry
2. Pupil size
3. Pupil shape
4. Pupil response
5. Iris color
6. Sclera color
7. Vision
8.Accomodation
9. Convergence
10. Eye Movement
Term
What is the nurse looking for when she inspects the ear?
Definition
1. Placement
2. Shape
3. Hearing
Term
What is the nurse looking for when inspecting the nose?
Definition
1. position
2. patency
3. drainage
Term
What is the nurse looking for when inspecting the mouth?
Definition
1. Mucous membrane (color/ moisture
2. Teeth
Term
What is the nurse looking for when inspecting the pharynx?
Definition
position of uvula
Term
What is the nurse looking for when inspecting the neck
Definition
1. trachea palpated in midline
2. no masses
Term
What is the nurse inspecting the chest for?
Definition
1. Color
2. Contour
3. Breathing patterns
Term
What does the nurse palpate the chest for?
Definition
1. Warmth
2. Moisture
3. Tenderness
4. Masses
Term
When inspecting the chest the nurse may
Definition
percuss
Term
When auscultating the thorax what sounds is the nurse listening for?
Definition
1. Bronchial sounds
2. Bronchovesicular sounds
3. Vesicular sounds
4. Adventitious sounds
Term
What is meant by bronchial sounds?
Definition
Sounds heard over trachea
Term
What is meant by bronchovesicular sounds
Definition
Sounds heard over mainstream bronchus
Term
What is meant by Vesicular sounds
Definition
Sounds heard over bases
Term
What is meant by Adventitious sounds?
Definition
1. Crackles- fine or course. course known as Rhonchi
2. Wheezes- high pitched and musical
3. Sonorous wheezes- deeper, snoring
Term
What do you inspect when assessing the heart?
Definition
1. inspection for apical impulse
2. palpate for pulsations
3. auscultate heart sounds
Term
What is the nurse assessing or looking for when auscalating heart sounds?
Definition
1. S1 lub
2. S2 dub
3. Aortic, pulmonic, tricuspid, and mitral areas
Term
When inspecting the breasts/ Axilla what is the nurse looking for?
Definition
1. size
2. shape
3. symmetry
4. color
5. texture
6. lesions
7. Areola/ nipples: size, shape, discharge, inversion
Term
When palpating the breast/ axilla what is the nurse looking for?
Definition
1. Each Quadrant
2. Tail of spence
3. Compress nipple
4. Nodes in Axilla
Term
When inspecting the Abdomen it is important to note the order of________
Definition
Techniques
Term
When inspecting the abdomen the nurse needs to look at________
Definition
1. Color
2. Contour
3. Pulsation
4. Umbilicus
Term
When auscultating the abdomen the nurse needs to listen for ___________
Definition
Bowel Sounds
Term
When the nurse purcuss the abdomen what are they looking for
Definition
1. Bladder
2. Each quad
Term
When the nurse palpates the abdomen the nurse is feeling for __________
Definition
1. Tenderness
2. Masses
Term
When inspecting the female genitalia the nurse looks at what?
Definition
1. the external genitalia
2. Uses the speculum to visualize the inside vagina
Term
When inspecting the male genitalia the nurse does what______-
Definition
1. inspects external
2. Palpates scrotum for masses
Term
When ispecting the urine the nurse looks for what______
Definition
1. color
2. Clarity
3. odor
4. amount
Term
When inspecting the endocrine
Definition
1. accuchecks
Term
When inspecting peripheral vascular extremities what is the nurse looking for?
Definition
1. color
2. temp
Term
When the nurse is palpating the peripheral vascular what is she feeling for?
Definition
1. peripheral pulses
2. capillary refill
Term
When assessing peripheral vascular the nurse may also check for swelling or____
Definition
edema
Term
When inspecting the muscles the nurse looks for
Definition
1. symmetry
2. ROM
Term
When palpating the muscles the nurse feels for
Definition
1. tenderness
2. Strength
Term
When inspecting the bones the nurse looks for
Definition
symmetry
Term
When palpating the bones the nurse feels for___________-
Definition
1. tenderness
2. crepitus
3. heat
4. swelling
Term
When the nurse is assessing the neurological they are assessing____________?
Definition
Mental status
a. orientation
b. loc
c. memory
d. reasoning
e. language
2. Cranial Nerve Function
3. Mortor Function: balance, gait, coordination
4. Sensory Function: Pain, Light touch, Vibration
5. Reflexes
6. Glascow Coma Scale
Term
What is assessed and looked for when assessing the Glascow Coma Scale
Definition
1. Assesses level of consciousness
2. Three Parameters: Eye Opening, Motor Response, Verbal Response
3 Score of 7 or less designates Coma
4. Top score is 15

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