Term
|
Definition
1 lb = 2.2 kg
1 in = 2.5 cm |
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Term
Respiratory Status
Normal vs. Impaired
Signs & Symptoms |
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Definition
Look for: Rate, Rhythm, Depth, & Quality
Rate should be 12-20/minute
Eupnea: Normal Rate & Depth
Tachypnea: Rate > 20-25/minute
Bradypnea: Rate < 12/mintue
Apnea: Absence of spontaneous respiration
Dyspnea: Difficulty Breathing
Use of Accessory Muscles?
Nail Clubbing?
Inspect skin...any pallor?
Inspect mucous membrane...any cyanosis?
Inspect thorax...intercostal retractions? |
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Term
|
Definition
Inspection
A:P = 1:2
Auscultation
Breath Sounds
Adventitous Sounds...rales, rhonchi, wheezes? |
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Term
|
Definition
Describe the apical impulse. Normal findings:
a. Location-4-5th ICS, L MCL
b. Size-1 to 2 cm. (size of nickel)
c. Amplitude-small, like gentle tap
d. Duration-short (first 2/3 of systole or less)
Palpate
Auscultate for pulse rate |
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Term
| Cardiac Auscultation - Location & Heart Sounds |
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Definition
• Aortic valve area - 2nd R ICS at RSB
• Pulmonic valve area - 2nd L ICS at LSB
• Second pulmonic area (Erb's point) - 3rd L ICS at LSB
• Tricuspid area - 4th L ICS at LSB
• Mitral (apical) - 5th L ICS at MCL
S1 - closure of AV valves (Tricuspid and Mitral valves), beginning of
systole and best heard toward the apex where it is louder
than S2. S1 is a lower-pitched, more pronounced sound than S2.
S2 - closure of the Aortic and Pulmonic valves. Best heard in the
2nd ICS at the right sternal border. S2 is higher-pitched
than S1 and has a clipped, closing sound. |
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Term
| Peripheral Pulses - Location & Grade |
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Definition
Note the following characteristics:
-Rate: Number of beats per minute
-Rhythm: the regularity of the beats
-Symmetry: pulses on both sides of the body should be similar.
-Amplitude: the strength of the beat, assessed on a scale of 0 to 4.
4 = Bounding
3 = Increased
2 = Normal
1 = Weak
0 = Absent or nonpalpable
Temporal, Carotid, Brachial, Radial, Femoral, Popliteal, Posterior Tibial, Dorsalis Pedis |
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Term
|
Definition
Arterial
-Blood does not get down to the extremity
-Pulses decreased or absent
-Pale color, especially when elevated;
dusky read when dependent
-Temperature of extremity is cold
-Edema may be absent or mild
-Skin is thin, shiny, and atrophic
-Loss of hair is seen over foot and
toes
-Nails are thickened and ridged
-Ulcers, if present, involve toes or
points of trauma on feet
-Skin around ulcer has no excess
pigment
-Pain is often severe unless
neuropathy masks it
-Gangrene may develop
-Pain:
• Comes on during exercise
• Quickly relieved by rest
• Intensity increases with the
intensity and duration of
exercise |
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Term
|
Definition
-Blood does not get back to the heart
-Prominent leg veins, may appear
ropelike and dilated or purplish and
spiderlike
-Lower leg edema may extend to
knee of affected extremity
-Affected leg hard and leathery to
touch
-Pulses normal, but may be difficult
to feel through edema
-Normal temperature
-Brownish skin pigmentation
-Gangrene does not occur
-Ulcers may occur at side of ankles
-Skin surrounding ulcers pigmented
and sometime fibrotic
-Pain is not severe
-Eczema or statis dermatitis
-Positive Homan’s sign
-DVT can cause pulmonary embolism
-Pain
• Pain comes on during and often
several hours after exercise
• Relieved by rest but sometimes
only after several hours or even
days; pain tends to be constant
• Greater variability than arterial
pain in response to intensity and
duration of exercise |
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Term
Testing for Homan's Sign
(Venous Insufficiency) |
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Definition
An indication of incipient or established
thrombosis in the leg veins in which
slight pain occurs at the back of the
knee or calf when, with the knee bent,
the ankle is slowly and gently
dorsiflexed. |
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Term
| Male - Penis, Scrotum, & Groin - Model |
|
Definition
Inspect:
• Pubic hare distribution – triangular, sparsely distributed on scrotum and inner thigh and absent on genis,
hair is coarser than scalp air, no nits or lice
• Penis – skin free of lesions and inflammation, shaft skin loose and wrinkled w/o erection, not penile
discharge. If uncircumcised loose skin on the penis shaft folds to cover glans forming the foreskin
• Scrotum skin appears rugated, thin, and more deeply pigmented
• Urethral Meatus – center of glans, pink to darker pink, no discharge
• Inguinal area free of swelling and bulges
Palpate:
• Penis – palpate entire length between thumb and first two fingers, note any pulsations, tenderness, masses,
or plagues. Retract foreskin if uncircumsized. Gently squeeze glans to expose meatus
• Scrotum – palpate:
An indication of incipient or established
thrombosis in the leg veins in which
slight pain occurs at the back of the
knee or calf when, with the knee bent,
the ankle is slowly and gently
dorsiflexed.
o testicle between thumb and first two fingers, note size, shape, consistency, and present of masses
• spermatic cord from the epididymis to external ring, not consistency and presence of tenderness and
masses. If mass noted darken room and apply light source to unaffected side behind scrotum and direct
forward, repeat with affected side
• Skin overlying the inguinal and femoral areas for lymph nodes, noting size, consistency, tenderness, and
mobility. To palpate inguinal hernias ask pt to bear down while you palpate the inguinal area, place dominant
index finger in client’s scrotal sac above testicle and invaginate the scrotal skin, follow spermatic cord until
you reach a triangular, slitlike opening (Hesselbach’s triangle)
Auscultate – if scrotal mass is detected ausculate scrotum to listen for bowel sounds, if present suggest a hernia
Cremasteric Reflex – stroke inner aspect of man’s thigh, response is elevation of testes is positive cremasteric
reflex – L1,2
Bulbocavernous reflex – apply pressure over bulbocavernosus muscle and gently pinch foreskin or gland, contraction
of the bulbocavernosus muscle is a + reflex response – S3,4 |
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Term
|
Definition
When changes position/posture is there a drop in systolic > 10 points. Don’t have enough
blood to circulate, often caused by dehydration |
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Term
|
Definition
Inspection:
Conical, symmetrical, or slightly asymmetrical
Skin color lighter than in exposed areas, no lesions, redness,
or edema; texture even
Striae often seen w/ breast enlargement during pregnancy
No dimpling or retraction
No increase in venous pattern unless client is pregnant
Nipples and Areolae:
Nipples everted, pointing in same direction, no discharge
or lesions
Areola and nipple darker than breast tissue
Supernumerary breasts or nipples are congenital anomalies
Palpate:
Breast soft, nontender
Nipples elastic, nontender. No discharge or white,
sebaceous secretions
Axilla and clavicular nodes
Supraclavicular nodes
Infraclavicular nodes
Central nodes
Lateral nodes
Posterior nodes
Anterior nodes
Epitrochlear nodes (nonpalpable) |
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Term
| Abdomen - Inspection & Auscultation |
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Definition
Inspection (Look across abdomen and look down abdomen):
Skin:
• General color
• Contour
• Lesions/lumps/masses
• Scars (transverse/vertical:location)
• Striae (stretch marks)
• Pink/purple = Cushing’s syndrome)
• Vascular changes
• Lesions
• Rashes
• Umbilicus (inverted/everted, displaced R or L)
• Signs of inflammation
Movement associated with:
• Peristalsis (visible only on very thin persons; increased in intestinal obstruction)
• Pulsations (aorta, increased pulsations=aneurysm or increased pulse pressure)
Skin (scars, striae, dilated veins, rashes/lesions)
Umbilicus
Contour of Abdomen (shapes): (flat, rounded, protuberant, scaphoid (markedly concave or hollow); regional/local
bulges; visible masses)
Know shapes, pulses at midline, listen for normal bowel sounds 5-30/min, listen before touch
Auscultation:
Place the diaphragm of your stethoscope lightly on the abdomen.
Listen for bowel sounds. Are they normal, increased, decreased, or absent?
Listen for bruits over the renal arteries, iliac arteries, and aorta with the bell of
the stethoscope.
Screen for:
• Bruits such as renal aortic aneurism, aorta; renal stenosis as cause of HTN
• Bowel sounds – bowel motility in all 4 quadrants (normal bowel sounds 5-
30/min)
Listen for bruits over renal, iliac, femoral, and aortic arteries |
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Term
| Abdomen - Palpation & Percussion |
|
Definition
Assess for pain
Light palpation:
Begin with light palpation. At this point you are mostly looking for areas of tenderness. The most sensitive
indicator of tenderness is the patient's facial expression. Voluntary or involuntary guarding may also be
present.
Proceed to deep palpation after surveying the abdomen lightly. Try to identify abdominal masses or areas
of deep tenderness.
Deep palpation:
Palpation of the Liver
Standard Method
Place your fingers just below the costal margin and press firmly.
Ask the patient to take a deep breath.
You may feel the edge of the liver press against your hand. Or it may slide under your hand as the
patient exhales. A normal liver is not tender.
Alternate Method
This method is useful when the patient is obese or when the examiner is small compared to the
patient.
Stand by the patient's chest.
"Hook" your fingers just below the costal margin and press firmly.
Ask the patient to take a deep breath.
You may feel the edge of the liver press against your hand.
Palpation of the Aorta
Press down deeply in the midline above the umbilicus. ++
The aortic pulsation is easily felt on most individuals.
A well defined, pulsatile mass, greater than 3 cm across, is suggestive of an aortic aneurysm. [p350]
Palpation of the Spleen
Use your left hand to lift the lower rib cage and flank. ++
Press down just below the left costal margin with your right hand.
Ask the patient to take a deep breath.
The spleen is not normally palpable on most individuals. [p346]
Rebound pain
This is a test for peritoneal irritation.
Warn the patient what you are about to do.
Press deeply on the abdomen with your hand.
After a moment, quickly release pressure.
If it hurts more when you release, the patient has rebound tenderness.
Percussion:
Percuss in all four quadrants using proper technique. [p338]
Categorize what you hear as tympanitic or dull. Tympany is normally present over most of the abdomen in
the supine position. Unusual dullness may be a clue to an underlying abdominal mass.
Empty bladder tympany
Full bladder dull
Visual |
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Term
| Visual Acuity - Snellen Chart |
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Definition
| 20 feet away (each tile square is a ~ foot), cover eye, read smallest can see with then without glasses |
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Term
| Extraocular Movement (EOM) & Visual Fields |
|
Definition
A given extraocular muscle moves an eye in a specific manner, as follows:
medial rectus (MR)—
moves the eye inward, toward the nose (adduction)
lateral rectus (LR)—
moves the eye outward, away from the nose (abduction)
superior rectus (SR)—
primarily moves the eye upward (elevation)
secondarily rotates the top of the eye toward the nose (intorsion)
tertiarily moves the eye inward (adduction)
inferior rectus (IR)—
primarily moves the eye downward (depression)
secondarily rotates the top of the eye away from the nose (extorsion)
tertiarily moves the eye inward (adduction)
superior oblique (SO)—
primarily rotates the top of the eye toward the nose (intorsion)
secondarily moves the eye downward (depression)
tertiarily moves the eye outward (abduction)
inferior oblique (IO)—
primarily rotates the top of the eye away from the nose (extorsion)
secondarily moves the eye upward (elevation)
tertiarily moves the eye outward (abduction)
Six cardinal gazes:
Cranial nerves 3, 4, and 6:
Each extraocular muscle is innervated by a specific
cranial nerve (C.N.):
medial rectus (MR)—cranial nerve III (Oculomotor)
lateral rectus (LR)—cranial nerve VI (Abducens)
superior rectus (SR)—cranial nerve III (Oculomotor)
inferior rectus (IR)—cranial nerve III (Oculomotor)
superior oblique (SO)—cranial nerve IV (Trochlear)
inferior oblique (IO)—cranial nerve III (Oculomotor)
The following can be used to remember the cranial nerve
innervations of the six extraocular muscles:
LR6(SO4)3.
That is, the lateral rectus (LR) is innervated by C.N. 6, the superior oblique (SO) is innervated by C.N. 4, and the
four remaining muscles (MR, SR, IR, and IO) are innervated by C.N. 3.
Light reflex
Cover and uncover
convergence—both eyes moving nasally or inward
divergence—both eyes moving temporally or outward
Amblyopia (lazy eye)
Nystagmus – rapid involuntary rhythmic eye movement, with the
eyes moving quickly in one direction (quick phase), and then slowly
in the other (slow phase). significant other than in lateral field |
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Term
| Pupillary Response & External Eye Exam |
|
Definition
Direct, concential, accomidation:
There are two pupillary reflexes-
The pupillary light reflex is the reduction of pupil size in response to light.
The pupillary accommodation reflex is the reduction of pupil size in response to an object coming close to the eye.
Both these reflexes affect both eyes, even if only one eye is stimulated.
The pattern of papillary response to light can help determine which of the cranial nerves is damaged. There are
two types of response assessed for each eye:
Direct pupillary reflex: whether each pupil constricts with light shone into the that eye
Consensual pupillary reflex: whether each pupil constricts with light shone into the other eye
The pupillary accommodation reflex reduces the size of the pupil when an object is close to the eye. A smaller pupil
produces a sharper image on the retina. There is also a separate accommodation reflex which changes the shape of the
lens so as to focus the image on the retina.
RED REFLEX:
Look through the ophthalmoscope and shine the light into the patient's eye from about two feet away.
You should see the retina as a "red reflex." (The Red Reflex: checks for a normal red reflection in the eye that
occurs when light travels inside the eye, hits the retina and the blood tissue, and is reflected back.) |
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Term
| Hearing Test - Rinne, Weber, & Whisper |
|
Definition
Rinne - Air > Bone = Normal
Weber - Lateraliztion
Whisper - Stand away from pt, shield mouth, & whisper one to two syllable word and have the pt repeat if they can hear it. |
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Term
|
Definition
| Palpating for nodulars etc, palpate lymph nodes |
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Term
| Face, Sinuses, & External Nose |
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Definition
| Symetry, landmarks – nasolabial fold, palpiable fissure, cranial nerve 5 |
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Term
| Oral Exam - External & Internal |
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Definition
External and internal
Rapidly changing cells, lesions in mouth are precancerous
Soft palate doesn’t rise - issues with CN 9 and 10
Teeth
Looking for hydration/anemia
Look at sides of tongue for oral lesions |
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Term
| Head & Neck - A&Vs and Nodes |
|
Definition
Inspection
head position
skull features
size, shape, symmetry, trauma
facial features
shape, symmetry, movement, expression
the “danger triangle”
tics, tremors
head position: should be upright and still;
horizontal jerking may be tremor; nodding movement may be associated with aortic insufficiency
head tilted to one side may be to favor a good eye or ear or due to torticollis (is a condition in which the head is
tilted toward one side, and the chin is elevated and turned toward the opposite side)
skull features: should be symmetrical
facial features: observe facial features at rest and with movement and expression pay particular attention to the
“danger triangle”...this area drained by the facial vein which has no backflow valves and as a result, infection in this
area can result in infection into brain, etc.
tics/tremors
Facial landmarks
palpebral fissures (The opening for the eyes between the eyelids)
nasolabial fold (The skin crease extending from the nose to a point lateral to the corner of the mouth)
Palpation
systematically from front to back:
symmetry
swelling
depressions
tenderness
scalp movement
temporal arteries
tenderness
thickening
hardness
temporomandibular joint (TMJ)
salivary glands
symmetry
tenderness
Arteries and veins:
Arteries
carotid
Veins
internal jugular
external jugular
Jugular veins look for distention:
ABNORMALLY DISTENDED JUGULAR VEINS MAY SIGNAL INCREASED ROGHT ATRIAL PRESSURE; FLAT
VEINS ARE A SIGN OF HYPOVOLEMIA. FOLLOW THESE TIPS TO GAUGE WHETHER YOUR PATIENTS
VENOUS PRESSURE IS NORMAL.
DON'T
Don't allow your patient to flex his neck during assessment.
Don't confuse venous and arterial pulsations.
DO
Prevent constriction of your patient's jugular veins by removing any clothing from around his neck and thorax.
With your patient lying in bed, stand at his side and have him turn his head slightly to the other side.
Visualize the approximate location of his carotid artery, internal jugular vein, and external jugular vein.
Slowly raise the head of your patient's bed to a 45- degree angle so you can see jugular venous pulsations. If you
have trouble detecting venous pulsation, shine a bright light on his neck from the side. This casts shadows on the
vessels and helps you see pulse wave movement.
Ensure that you're gauging venous pulsation, which varies during breathing or position changes. Arterial pulsation
isn't affected.
Ascultate:
Rate with diaphragm
Bruit with bell
Lymph nodes
preauricular
posterior auricular
occipital
tonsillar
submandibular
submental
superficial (anterior) cervical
deep cervical
posterior cervical
supraclavicular |
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Term
| Neck - Thyroid, Trachea, ROM, muscles |
|
Definition
Thyroid (lean to side assessing), trachea, ROM, muscle
Inspection
symmetry
alignment of trachea
fullness (thyroid?)
masses, webbing, skin folds
jugular vein distention
carotid artery prominence
range of motion
Palpation
tracheal position
tracheal tug
hyoid bone
thyroid and cricoid cartilage
Thyroid Gland
Palpation
either from front or behind patient…be consistent
neck flexed forward...tilted toward side being examined
sips of water facilitate swallowing
Note:
size
shape
configuration
consistency
tenderness
nodules
Auscultation: If the thyroid is enlarged, listen with the bell of the stethoscope for vascular sounds. |
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Term
| Reflexes - DTR & Superficial |
|
Definition
5 DTR’s and superficial
Know sites, know grades, know Babinski’s:
Superficial reflexes. Stroke the skin with a hard object such as an applicator stick. What is felt is a superficial
reflex.
Deep tendon reflexes are often rated according to the following scale:
0: absent reflex
1+: trace, or seen only with reinforcement
2+: normal
3+: brisk
4+: nonsustained clonus (i.e., repetitive vibratory movements)
5+: sustained clonus
Deep tendon reflexes are normal if they are 1+, 2+, or 3+ unless they are asymmetric or there is a dramatic
difference between the arms and the legs. Reflexes rated as 0, 4+, or 5+ are usually considered abnormal. In
addition to clonus, other signs of hyperreflexia include spreading of reflexes to other muscles not directly being
tested and crossed adduction of the opposite leg when the medial aspect of the knee is tapped.
-Biceps: Deep tendon reflex
-Triceps: Deep tendon reflex
-Plantar (Babinski)
-Patellar (knee jerk)
-Achilles (ankle jerk) |
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Term
| Cerebellar Function & Mental Status |
|
Definition
Know:
Mental Status.:
Level of consciousness. The single most valuable indicator of neurologic function is the individual's level of
consciousness. Determine the patient's level of consciousness -- alert, lethargic, stupor, semicoma, or coma.
NOTE: Legally, only physicians are authorized to make such determinations. You can legally describe the patient's
condition in the nursing notes by saying, "appears to be" alert or lethargic or so forth.
Alert. The patient is awake and verbally and motorally responsive.
Lethargic. The patient is sleepy or drowsy and will awaken and respond appropriately to command.
Stupor. The patient becomes unconscious spontaneously and is very hard to awaken.
Semicoma. The patient is not awake but will respond purposefully to deep pain.
Coma. The patient is completely unresponsive.
Calculations in basic mathematics. Ask the patient to do some simple arithmetic problems without using paper and
pencil. For example, ask him to add 7s or to subtract 3s backwards. It should take the patient of average
intelligence about one minute to complete the calculations with few errors.
Affect/mood. During the physical part of the examination, note the patient's mood and emotional expressions
which you can observe by his verbal and nonverbal behavior. Notice if he has mood swings or behaves as though he
is anxious or depressed. Notice whether or not the patient's feelings are appropriate for the situation.
Disturbances in mood, affect, and feelings may be indicated by a patient who exhibits unresponsiveness,
hopelessness, agitation, euphoria, irritability, or wide mood swings.
Memory (recent and remote). Ask the patient his social security number, the city he is in, the building number,
the state, and the names of two or three past presidents of the United States.
Knowledge (normal intellect). Ask the patient to name five large cities, major rivers, etc. Another way to test this
area is to ask the patient to tell you the meaning of a fable, proverb, or metaphor. For example, explain:
Too many cooks spoil the soup.
A penny saved is a penny earned.
A stitch in time saves nine.
A person of average intelligence should be able to explain any of these phrases. A person who can't explain any of
these phrases may have organic brain syndrome, brain damage, or lack of intelligence.
Orientation to name, date, location, President
3 word test
Count backwards
(Mini mental status scale
Glasco Coma Scale (for exam, can’t really check
in lab)) |
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|
Term
| Cerebellar Function & Coordination |
|
Definition
Cerebellar Functions. These include tests for balance and coordination. The cerebellum controls the skeletal
muscles and coordinates voluntary muscular movement.
Finger-to-nose test. With his eyes open, instruct the patient to touch his index finger to his nose.
Rapid alternating movements test. Seat the patient. Instruct him to pat his knees with his hands, palms down then
palms up. Have him alternate palms down and palms up rapidly. Watch the patient to notice if his movements are
stiff, slow, nonrhythmic, or jerky. The movements should be smooth and rhythmic as he does the task faster.
Rom berg test. Instruct the patient to stand with his feet together and his arms at his side. Have the patient do
this with his eyes open and then with his eyes closed. (Stand close to the patient to keep him upright if he starts
to sway.) Expect the patient to sway slightly but not fall. This is a test of balance. If the patient really loses his
balance, he may have cerebellar ataxia or vestibular dysfunction.
-Romberg
-Heel to Shin
-Finger to Nose |
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Term
| Upper Extremities - ROM, Joints, Muscles, Sensory |
|
Definition
Shoulder, total arm, elbow, wrist, fingers, pulses
How measure ROM – goniometer to measure ROM (will not have to perform, just mention) |
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|
Term
| Lower Extremities - ROM, Joint, Muscles, Sensory |
|
Definition
Hip, knee, ankle, toe
Assess muscle strength against resistance
How measure ROM – goniometer to measure ROM (will not have to perform, just mention) |
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