Physical Health Assessment: Exam 2

What is cranial nerve 1 (olfactory)

identify different smell with each nostril separately and with eyes closed unless such condition like colds is present

What is cranial nerve 2 (optic)

the client should be able to read with each eye and both eyes

What is cranial nerve 3 (oculomotor 1)

illuminated and non-illuminated pupil should constrict

What is cranial nerve 3 (oculomotor 2)

pupils constrict when looking at a near object, dilate when looking at a distant object, converge when near object is moved toward the nose

What is cranial nerve IV (trochlear)

client’s eyes should be able to follow the penlight as it moves

What is cranial nerve V (trigeminal)

clients should have a (+) corneal reflex, able to respond to light and deep sensation and able to differentiate hot from cold

What is cranial nerve VI (abducens)

both eyes coordinated, move in unison with parallel alignment

What is cranial nerve VII (facial)

client should be able to smile, raise eyebrows, and puff out cheeks and close eyes without any difficulty. The client should also be able to distinguish tastes

What is cranial nerve VIII (vestibulocochlear)

client should be able to hear the tickling of the watch in both ears and should have upright posture and steady gait and able to maintain balance

What is cranial nerve IX (Glossopharyngeal)

Clients should be able to elicit gag reflex and swallow without any difficultly

What is cranial nerve X (Vagus)

The client should be able to swallow without difficulty and speak audibly

What is cranial nerve XI (accessory)

client should be able to shrug shoulders and turn head from side to side

What is cranial nerve XII (hypoglossal)

the client should be able to move tongue without any difficulty

Where and what is the second intercostal space?

right and aortic

Where and what is the second intercostal space (2)

left (pulmonary)

Where and what is the third intercostal space

left (Erb)

Where and what is the fourth intercostal space

left (triscupid)

Where and what is the 5th intercostal space?

left (mitral)

What is the anatomy of the upper respiratory system?

nose, nasal cavity, sinuses, pharynx, and larynx

What is the anatomy of the lower respiratory system?

trachea, bronchi, bronchioles, lungs, and alveoli

What are the respiratory lines for midsternal

down center of sternum

What is the respiratory anatomical lines for midclavicular

from middle of clavicle over nipple and down to lower rubs on left and right chest wall

What is the respiratory anatomical lines for axillary lines?

down the axilla to lower rib cage

What is the respiratory anatomical lines for posterior lines

scapular lines (inferior angle of scapula), vertebral line (down spinous process of spine)

What is the respiratory lung lobes: right upper lobe

above clavicle and extends to fourth rib

What is the respiratory lung lobe: right middle lobe

extends to sixth rib

What is the respiratory lung lobe for RLL

more lateral, extends to eighth rib (visible laterally)

What is the respiratory lung lobe for LUL

above clavicle to sixth rib

What is the respiratory lung lobe for LLL

wedge shaped ending at eighth rib

Is the right or left lobe smaller than the other?

right lobe is smaller

Why is the right lobe smaller than the left lobe?

because of the liver

What are the accessory structures?

diaphragm and intercostals muscles

What is the apex of the heart?

at the bottom of the heart where the PMI is between the 5th and 6th intercostal on the left side

What is capillary’s function?

sites of exchange between blood and tissues

What does arteries do?

carry blood away from the heart

What does veins do?

return blood to the heart

What is the cardiac cycle?

process of blood flowing through all components of heart

What is the systole

contraction, pumping blood out

What is diastole

relaxation, chambers fill with blood

What does PERRLA stand for?

pupil, equal, round, reactive to light, and accommodation

What range is the eye opening for glasgow coma scale?

1 being no response to 4 being spontaneously

What is the verbal response range for glasgow coma scale?

1 being no response to 5 being oriented to time, person, situation, and place

What is the motor response range for glasgow coma scale?

1 being no response and 6 being obeys command

What does accommodation mean for Perrla?

pupils constrict at object close (nose) then dilate when asked to look at far object

What is the function for cranial nerve 4

trochlear (pt should follow penlight up, down, side, and diagonally with penlight 1ft away)

What is the function for cranial nerve 5

trigeminal (blink, pain, and hot and cold sensation)

What is the function for cranial nerve 6

abducens (six cardinal fields of gaze with penlight and eyes should move parallel in unison

What is the function for cranial nerve 7

facial (facial expression, taste test—— distinguish between various tastes)

What is the function for cranial nerve 8

vestibulocochlear (steady gait, posture, and ticking test for hearing)

What is the function for cranial nerve 9

glossopharyngeal (gag relax, swallowing, and saying ah)

What is the function for cranial nerve 10

Vagus (swallowing and speaking at the same time)

What is the function for cranial nerve 11

accessory (shoulder shrug and head turn side to side)

What is function for cranial nerve 12?

hypoglossal (tongue movement to check for the midline of the tongue from side to side)

What are the appropriate techniques and indications for incentive spirometry?

used to facilitate deep breathing, recommended to use every four 4-10 times, decrease or prevent atelectasis, helps mobilize secretions to expectorate if followed up by cough.

Which types of pt would benefit from incentive spirometry?

atelectasis, decreased lung expansion, pneumonia, post-op, and bed rest

What are some examples of problems in the cardiac assessmen that can impact data in skin assessment?

peripheral venous disease causing thin, shiny skin

What are some examples of skin assessment that can hint at cardiovascular problems?

cyanosis possibly meaning bad circulation

JVD is common in people with what?

CHF (especially right sided heart failure)

What causes murmurs and heart sounds

presence of S3 and S4 sounds, diaphragm can be used to measure, and indicate heart disease and valve malfunction

What is decreased circulation venous signs

superficial veins, brown coloring due to edema, aching/bruise

What is decreased arterial signs?

cool, thin/shiny skin, no edema, and +1 pulses

In glasgow coma scale is considered mild?

13-15

in glasgow coma scale what is considered moderate?

9-12

In glasgow coma scale what is considered severe?

8 and lower

What is friction rub

low pitch, grating/coarse tone, inflammation of the pleura and is very painful, both inhale and exhale

What is fine crackles

high-pitched, bubbling, crackling, pneumonia, inhalation, partially deflated alveoli to pop open

What is coarse crackles

low pitched, bubbling, crackles, pneumonia, inhalation, do not clear up with cough

rhonchi

low-pitched, snoring, COPD, sometimes clear with coughing, and both inhalation and exhale

What is wheezing?

whistling, high-pitched, asthma, allergies, both inhale and exhale, narrowing of the airways

What is stridor

high-pitched, upper airway obstruction, crowning sound

What is S1

lub and is the closing of the mitral and triscupid valves

Where is S1 best heard

at the apex (location of PMI or apical pulse) and has a low dull pitched sound

What is S2

dub and the closing of the aortic and pulmonic valves

Where is S2 best heart at?

the base of the heart and slighly higher

What are health promotions for head neck and neurological?

prevention education and health screenings such as vision, hearing, and dental

What are health promotion interventions for respiratory?

social habits and education such as tobacco use and immunization

What are some health promotions interventions for cardiovascular

annual screenings such as blood pressure glucose cholesterol, exercise, stress reduction, dietary changes, alcohol and tobacco