Fundamentals Chapter 21 Physical Assessment Flashcards | Knowt (2024)

Accommodation Response

measures the eye muscles to focus on an image up close and in the distance

Adventitous Breath Sounds

abnormal breath sounds(crackels, rhonchi, wheezes, pleural friction rub and stridor)

Atelectasis

lack of or decreased excursion on one side of the chest by severe pneumonia or lung collapse

Auscultation

listening to sounds produced by the body

Auscultation anterior

front of body, 3 lines, midsternal line, left and right midclavicular line

Auscultation laterally

from side, 3 lines, midaxillary line, anterior and posterior axillary line

Auscultation posterior

back of body, 3 lines, midspinal line, right and left scapular line

Bronchial breath sounds

heard over bronchi, upper part of sternum, shorter inspiratory phase and longer expiratory phase, louder and more harsh sounds than the others

Bronchovesicular sounds

over middle of chest and sternum, more equal sounding and less harsh

Vesicular sounds

over periphary of lungs, longer inspiratory phase and experiatory phase, softer rustling sounds

Cheilitis

inflammation of lips, as well as dryness and cracking

consensual reflex

optic nerve divides(bifurcates) at the distal end, stimulation of the nerve by shining a light in either eye should cause both pupils to rapidly constrict simultaneously and equally

crackle)

not continuous and usually heard during inspiration, may be fine(softer more high pitched) or coarse (louder and low pitched)

dysphagia

individual having difficulty coordinating and organizing words in sentence correctly

eructation

heard with the naked ear, belching, passing of flatus or rectal gas, loud wheezing or gurgling and loud bowel movements

excursion

equal chest expansion as pt inhales on both sides

guarding

defense mechanism of tightening the abdominal muscles to prevent further compression of tender or inflamed areas

Halitosis

bad breath, poor oral hygiene, sinus infection, gastric upset or high stress

Jaundice

yellow or oranging coloring of skin and mucous membranes, detected in sclera and palm of hands, caused by liver

lethargic

drowsy or mentally sluggish

opthalmoscope

lighted instrument used to assess or examine the internal structure of the eyes

otoscope

lighted instrument used to assess or examine the lining of the nose, tympanic membranes and ear canals

palpation

palpate the 4 quadrants of the abdomen to determine whether it is soft, firm or hard

order of palpating and auscultating bowels

RLQ, RUQ, LUQ, LLQ

paresthesia

numbness or decreased sensation of skin, if present there is a nerve impairment, commonly seen as a complication of diabetes, result of stroke or traumatic event

percussion

striking body parts with tips of fingers, elicits sounds that can help locate and determine the size of structures below the surface, identifies if structure is hollow or solid, detects areas containing air or fluid

peristalsis

wavelike muscular contractions of the intestines that move intestinal content through the alimentary canal, where absorption of nutrients and water takes place, toward the rectum for elimination

normal bowel sounds

5 to 30 clicks or gurgles per minute in each quadrant, high pitched sounds known as active bowel sounds

hypoactive bowel sounds

under 5 gurgles per minute

hyperactive bowel sounds

over 30 gurgles per minute

borborgymus

gurgling bowel sounds heard without stethoscope

PERRLA

Pupils Equal Round Reactive to Light and Accommodating

ptosis

drooping eyelids on one side, usually caused by stroke

retractions

if chest wall appears sunken in between the ribs or under the xiphoid process when patient inhales. indicate respiratory problems that need attention

rhonchi

sounds of lungs snoring, rattling, squeaking, low pitched wheezes. caused by secretions in airway

signs

what the nurse observes

symptoms

what the patient says

solar lenigines

older adults have many spots of yellowish brown discoloration caused by sun exposure. also known as liver spots

sordes

dried mucous or food cakes to lips or teeth. treat with good oral hygiene

stridor

can be heard without stethoscope and is a sign of life threatening upper airway obstruction, caused by a foreign body, tumor, swelling or bronchial spasms

turgor

skin elasticity

wheezes

melodious, musical or whistling sounds in lungs, caused by constriction in airway on inspiratory or expiratory

olfaction

smelling

subjective

interviewing

5 techniques are used to collect objective data in the performance of physical assessment

inspection, palpation, percussion, auscultation and olfaction

when auscultating bowels

inspection, auscultation, palpation, percussion and olfaction

ascites

use palmer surface of hand and palpate for masses below skin surface and accummulation of fluid in the peritoneal cavity

rebound tenderness

reflexive tensing of abdominal muscles or verbalization of pain with the release of deeper pressure. common in appendicitis

which side hands used for temperature

dorsal

assessments start with

height, weight and vitals

HEENT

assessment of Hair, Eyes, Ears Nose Throat

cloudiness of eyes

infection or low vitamin A

opaqueness of lens

cataract

anisocoria

pupils different size, unless born that way it is a neuro impairment

leukemia

reddish purplish or hemorrhagic appearing gums

periodontal disease

receding gums

fungal infection in mouth

black hairy appearing tongue

pernicious anemia

red, beefy tongue caused from lack of B12 used to be considered deadly

glossitis

smooth painful tongue caused by meds or inflammation

anaphlaxis

life threatening allergic response

flexor posturing

arms flexed to chest, hands clenched to fists and rotated internally, feet extended indicates problem above brainstem

extension posturing

arms extended, hands clenched into fists, wrists flexed and forearms severely pronated(internally rotated) indicated problem is mid brain or pons

AAO X 4

Awake Alert and Oriented in all 4 spheres

frothy or pink tinged sputum

pulmonary edema(worsening CHF)

blood tinged sputum

tuberculosis

rust colored sputum

pneumonia

posterior view of spine with curvature to either right or left

scoliosis

midthorax increased lateral view

kyphosis

curve of midthoracic and curve at lumbar

lordosis

eupnea

normal breathing

tachypnea

increased respiratory rate

bradypnea

decreased respiratory rate

kussmaul

deep and rapid breaths

cheyne stokes

gradually increased from shallow breaths to large breaths back to shallow followed by 5 to 60 seconds of apnea

apnea

no breaths

how many mL should kidneys produce per hr

30 mL

pallor

inadequate blood volume

erythema

inflammation or blockage of venous return