NUR131 Physical Assessment | Baamboozle - Baamboozle

Normal bowel sounds should occur in every __ to ___ seconds in each of the __ _______.

5 to 34, 4 quadrants

When auscultating the lungs you listen to ____ spots on the front and _____ spots on the back?

5 and 9

There are 12 cranial nerves. Name three and what they control

pg 735

The newer FOUR score coma scale is more useful for assessing critical patients that have been intubated. What four areas are scored?

Eye response, Motor response, Brainstem reflexes (pupils), and Respiration

The Glasgow coma scale is used to monitor three key categories of activity in the higher centers of the brain. Name them

eye opening, verbal response and best motor response (a score of 7 or less defines a coma)

Name at least 3 things the neurologic assessment assesses

Cerebral function, cerebellar function, cranial nerve function, motor and sensory function and reflexes

When checking the spine two abnormal findings are?

Scoliosis (lateral curve) and Kyphosis(thoracic curve that is increased) or lordosis (increase in the lumbar curve (seen in pregnancy and obesity)

An external exam of the rectum reveals hemorrhoids. What is a hemorrhoid?

Dilated veins appearing as reddened protrusion.

In a regular health history and physical exam, the anus and rectum are always assessed by the nurse. True or False?

False. Typically questions are asked about bowel patterns and habits, family history of colon cancer, history of anal intercourse and history of blood or mucus

Should the scrotum be symmetrical?

It can be normal for the left side to hang lower than the right

What are a few indicators the patient has an STD?

Foul smell, lesions, warts, discharge that isn’t white or clear

Bruits indicate arterial stenosis/occlusion. Describe how and where to assess for bruits.

Auscultate over arteries above umbilicus and over the carotid for bruits using the bell of the stethoscope

When listening to bowel sounds you should listen for ________min before documenting an absence?

2

Two abnormal findings in the abdomen would be?

Distension, Swelling, masses, unusual pulsations, asymmetry

Describe an abnormal breast exam on a male or female

Dimpling, puckering, nipple discharge, lesions and asymmetry

Neurovascular status can be remembered with 6 P’s. Name three

Pain, Pallor, Peripheral pulses, paresthesia (sensation), Paralysis, Pressure

Normal capillary refill is documented as ________

CRT <3 seconds

When documenting a pulse, how would you document normal radial pulses?

2+, regular and equal bilaterally

New murmurs or change in existing murmurs is more of a concern than regular old murmurs. True or False?

True. New or changed murmurs show that something has changed most likely in the valve function

True or False- S1, S2, S3 and S4 can all be normal

True: S1-Lub-Beginning of systole, closure of AV valves.S2-Dub-closure of the semilunar valves. S3- (lub, Dub) Dee-normal in children and young adults.

The bell of the stethoscope is used to listen to low pitched sounds. The diaphragm is used to listen to high pitched sounds. Which should you do first when performing an assessment?

Diaphragm is used first, it detects the normal heart sounds. Then use the bell to listen for extra sounds and murmurs.

The pulsation at the fourth or fifth intercostal space midclavicular line is called______ and is considered__________

Apical Impulse, Normal (Pulsations anywhere else is considered abnormal)

Name and describe three adventitious breath sounds

wheeze , rhonchi (sonorous wheeze), crackles (fine or course aka rales), stridor, decreased lung sounds, absent lung sounds, friction rub

The Chest should be symmetric with the transvers diameter greater than the anteroposterior diameter. What is it called when the anteroposterior diameter is greater and what illness do you see this in?

Barrel chest. Chronic lung disease aka COPD

Common changes for older adults for the head are

Impaired hearing, elongated ear lobes, decreased vision, decreased neck ROM, nodular thyroid gland, decreased adaptation to light and dark

The thyroid should not be palpable. If it is it should be soft but elastic, nontender, without masses or nodules. True or False?

True (Masses, tenderness and enlargement can indicate CA, Infection or gland disease)

If palpable, lymph nodes should be?

Small, smooth, nontender and movable.Normal to be nonpalpable

Describe a normal finding for the trachea

Midline, and in alignment with the suprasternal notch

Is venous neck distention normal or abnormal? Does distention indicate anything? If so, what?

Abnormal. Indicates kinking of vessel or aneurism if only on one side, increased CVP (heart problems) if both sides

When assessing the mouth you check

Teeth,Soft Palate,Uvula, Buccal Mucosa, Lips, Salivary glands,Tongue,Gums,Hard palate, tonsils

When checking the sinuses you need to palpate the sinuses for tenderness. Identify and point out where two sinus cavities are located

Frontal, near the eyebrows. Maxillary-the bony prominence of the upper cheek

The Tympanic membrane should be

Intact, translucent, shiny and gray (The ear canal should be smooth and pink. Free of foreign body, discharge and wax build up)

State the normal findings from an external ear exam

Ears are symmetrical bilaterally and proportional to head. Skin is dry and intact, no lesions, no edema noted. Pt denies pain with palpation

The cardinal fields of vision test?

Extra ocular movement (normally both eyes move together and are coordinated and parallel)

When using a snellen chart the patient should start by standing ____ feet away

20 (20/20 vision)

The white part of your eye is called?

Sclera (red part is conjunctiva, iris is colored part, pupil is black center)

Name at least one abnormal finding of the head

Periorbital edema, involuntary facial movement, Asymmetry, abnormal sizes or shapes, lesions, tenderness

The parts of the head and face should be proportional to each other and _________?

symmetrical

What angle is the nail if it is considered clubbed nails?

180 degrees

What angle is the nail if it is considered spoon nails?

less than 160 degrees

The angle between the nail and its base should be about __?__ degrees

160

Where is the best area to check for cyanosis, jaundice or pallor in a dark skinned individual?

Eyes, oral mucous membranes, palms, soles and lips

What is cyanosis?

bluish or grayish coloring of the skin/nailbeds/lips due to lack of oxygenation

What is jaundice?

yellowing of the skin and sclera

What is pallor?

paleness

When inspecting the hair name three things you look for-

Color, texture, distribution, pigmentation

Name three things that would make you question if a mole was malignant

Asymmetry, Irregular border. Color variation, diameter larger than a pencil eraser, pt reports a recent change in it.

When percussing over the lung field you should hear?

Resonance (in normal air filled lungs)

Percussion is used to?

Check the location, size, shape and density of tissue.

If the patient is in the Sims position, how are they positioned?

Laying on either side with both knees flexed and the top knee more acutely flexed

When obtaining height and weight of a patient, what is the name of the measurement we use to determine if a person is overweight, underweight or normal?

BMI

When checking skin temperature it is best to use what part of the hand?

the back of your hand

Palpation uses the sense of touch. Name three things you are assessing when using palpation

Firmness, contour, shape, tenderness and consistency. Skin texture and edema. Checking for lumps, temperature, moisture, turgor

What order should you perform the four steps of assessment on the abdomen?

Inspect, Auscultate, Percuss, then Palate

What area of the body does not follow the usual four step order?

The Abdomen

The four steps of the physical assessment process are:

Auscultate, Inspect, Palpate, Percuss