What is cyanosis?
bluish or grayish coloring of the skin/nailbeds/lips due to lack of oxygenation
Percussion is used to?
Check the location, size, shape and density of tissue.
What is pallor?
paleness
Describe an abnormal breast exam on a male or female
Dimpling, puckering, nipple discharge, lesions and asymmetry
An external exam of the rectum reveals hemorrhoids. What is a hemorrhoid?
Dilated veins appearing as reddened protrusion.
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
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 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 pulsation at the fourth or fifth intercostal space midclavicular line is called______ and is considered__________
Apical Impulse, Normal (Pulsations anywhere else is considered abnormal)
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
Name at least one abnormal finding of the head
Periorbital edema, involuntary facial movement, Asymmetry, abnormal sizes or shapes, lesions, tenderness
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
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)
Neurovascular status can be remembered with 6 P’s. Name three
Pain, Pallor, Peripheral pulses, paresthesia (sensation), Paralysis, Pressure
The four steps of the physical assessment process are:
Auscultate, Inspect, Palpate, Percuss
Two abnormal findings in the abdomen would be?
Distension, Swelling, masses, unusual pulsations, asymmetry
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.
When checking skin temperature it is best to use what part of the hand?
the back of your hand
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
When using a snellen chart the patient should start by standing ____ feet away
20 (20/20 vision)
When documenting a pulse, how would you document normal radial pulses?
2+, regular and equal bilaterally
If palpable, lymph nodes should be?
Small, smooth, nontender and movable.Normal to be nonpalpable
The cardinal fields of vision test?
Extra ocular movement (normally both eyes move together and are coordinated and parallel)
When listening to bowel sounds you should listen for ________min before documenting an absence?
2
When inspecting the hair name three things you look for-
Color, texture, distribution, pigmentation
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
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
When auscultating the lungs you listen to ____ spots on the front and _____ spots on the back?
5 and 9
Normal capillary refill is documented as ________
CRT <3 seconds
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)
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 order should you perform the four steps of assessment on the abdomen?
Inspect, Auscultate, Percuss, then Palate
What angle is the nail if it is considered clubbed nails?
180 degrees
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)
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 angle between the nail and its base should be about __?__ degrees
160
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)
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
What angle is the nail if it is considered spoon nails?
less than 160 degrees
Normal bowel sounds should occur in every __ to ___ seconds in each of the __ _______.
5 to 34, 4 quadrants
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.
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)
The parts of the head and face should be proportional to each other and _________?
symmetrical
Describe a normal finding for the trachea
Midline, and in alignment with the suprasternal notch
The white part of your eye is called?
Sclera (red part is conjunctiva, iris is colored part, pupil is black center)
What is jaundice?
yellowing of the skin and sclera
When assessing the mouth you check
Teeth,Soft Palate,Uvula, Buccal Mucosa, Lips, Salivary glands,Tongue,Gums,Hard palate, tonsils
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
There are 12 cranial nerves. Name three and what they control
pg 735
What area of the body does not follow the usual four step order?
The Abdomen
What are a few indicators the patient has an STD?
Foul smell, lesions, warts, discharge that isn’t white or clear
Should the scrotum be symmetrical?
It can be normal for the left side to hang lower than the right
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
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