Chapter 30: Physical Assessment & Health History

Abnormal extra breath sounds (like crackles or wheezes) heard when listening to the lungs with a stethoscope.

Framework Example: A nurse hears wet rattling crackles caused by fluid backing up into the air sacs from heart failure, recognizing this acute breathing crisis means the patient needs the head of the bed raised and oxygen prepped immediately before handling routine tasks.(ABCs (Airway, Breathing, Circulation))

Adventitious sounds

Partial or complete loss of hair that can happen naturally or from medical treatments like chemotherapy.

Framework Example: A patient receiving cancer medications expresses severe anxiety and refuses to leave their hospital room due to sudden hair loss from the drugs destroying rapidly dividing cells, prompting the nurse to prioritize therapeutic active listening and emotional support over routine physical care.(Physiological vs. Psychosocial (Early Clinical Deterioration))

Alopecia

A brain problem that makes it hard for a person to speak, write, or understand spoken language.

Framework Example: A patient who had a sudden stroke in the left side of the brain cannot find the words to express their basic needs, so the nurse prioritizes using a simple picture board as a low-stress communication tool to ensure the patient can easily signal a safety emergency.(Least Restrictive / Least Invasive)

Aphasia

The specific spot on the left side of the chest where the heartbeat can be felt most strongly against the chest wall.

Framework Example: A nurse finds the lower tip of the heart is pushed far to the left of its normal spot because a failing heart muscle has stretched out and enlarged, signaling an unstable decline in heart health that requires an immediate call to the doctor before giving heart medications.(Stable vs. Unstable)

Apical impulse or point of maximal impulse (PMI)

A white, gray, or blue ring that forms around the clear outer edge of the eye due to lipid deposits in older adults.

Framework Example: A nurse notices a gray ring around the outer edge of an eighty-year-old patient's eyes caused by normal fat build-ups over time, recognizing this is an expected finding for this age group that does not harm vision and requires only simple documentation rather than an emergency intervention.(Expected vs. Unexpected)

Arcus senilis

Wasted away, thinned out, or shrunken in size due to a lack of use, poor blood flow, or nerve damage.

Framework Example: A nurse notes the calf muscle of a patient who wore a heavy fiberglass cast for six weeks has shrunken significantly from lack of movement, recognizing this expected finding means the nurse should focus on safe physical therapy coordination rather than treating it as an acute injury.(Expected vs. Unexpected)

Atrophied

The act of listening to the internal sounds of the body, like the heart, lungs, or bowels, typically using a stethoscope.

Framework Example: A nurse uses a stethoscope to listen to the breath sounds of a patient with worsening asthma and hears tight squeaking sounds caused by narrowed air tubes, identifying an acute breathing emergency that dictates immediate administration of a rescue inhaler.(ABCs (Airway, Breathing, Circulation))

Auscultation

Loud, rumbling, or gurgling sounds made by gas and fluid moving through the intestines.

Framework Example: A nurse hears loud rumbling stomach noises caused by hyperactive bowel contractions in a patient who has been fasting, identifying this as an expected baseline finding that requires no medical intervention other than offering a meal.(Expected vs. Unexpected)

Borborygmi

An abnormal blowing or swishing sound heard through a stethoscope over an artery, caused by rough or blocked blood flow.

Framework Example: A nurse hears a swishing sound over a patient's neck artery caused by dangerous blood turbulence from a heavy fat buildup, recognizing this as an actual high-risk blockage that requires immediate stroke precaution setup rather than waiting for a potential future emergency.(Actual vs. Potential (Problems over Risks))

Bruit

Earwax, which is a sticky substance produced by glands in the ear canal to trap dirt and protect the ear.

Framework Example: A nurse looks into an older patient's ear canal and sees it is completely blocked by hard earwax build-up, recognizing this local hearing obstacle must be resolved with gentle ear drops before assessing for systemic brain or nerve confusion.(Systemic vs. Local ("Life over Limb"))

Cerumen

A flattening and widening of the fingertips and nails that happens when the body does not get enough oxygen over a long time.

Framework Example: A nurse notes a patient's fingertips are wide and the nails curve downward like a spoon due to long-term tissue oxygen shortage from chronic lung disease, recognizing this chronic stable state requires baseline oxygen monitoring rather than an acute emergency call.(Acute vs. Chronic)

Clubbing

Redness and swelling of the clear membrane lining the eyelid and eye, often called pinkeye, caused by infection or allergies.

Framework Example: A nurse notes a patient has red, bloodshot eyes with thick yellow drainage caused by a highly contagious bacterial invasion, dictating that the nurse immediately isolate the patient and enforce strict handwashing to stop the spread of infection.(Safety & Infection Control)

Conjunctivitis

A state of being stretched out, swollen, or bloated beyond normal limits, usually from trapped gas or fluid.

Framework Example: A nurse finds a patient's stomach is tightly bloated and firm because fluid or gas is trapped behind a completely blocked bowel, identifying an actual mechanical problem that requires inserting a stomach tube to drain the pressure before potential tearing occurs.(Actual vs. Potential (Problems over Risks))

Distention

An abnormal, irregular, or skipped rhythm of the heartbeat caused by a malfunction in the heart's electrical system.

Framework Example: A nurse tracks an irregular heartbeat on a monitor caused by an electrical glitch in the heart muscle, recognizing this unstable rhythm can suddenly stop blood delivery to the brain and requires an immediate check of the patient's pulse and blood pressure.(Stable vs. Unstable)

Dysrhythmia

An abnormal turning outward of the lower eyelid, which exposes the inner lining of the eye and causes irritation.

Framework Example: A nurse notes an older adult's lower eyelid is drooping outward due to a natural loss of muscle tone from aging, identifying an expected age-related change that requires simple protective eye drops rather than an emergency surgery referral.(Expected vs. Unexpected)

Ectropion

Swelling caused by excess fluid trapped in the tissues of the body.

Framework Example: A nurse notes deep pitting swelling in both lower legs caused by fluid backing up from a failing heart muscle, recognizing this systemic fluid overload problem takes priority over a localized skin scrape on the patient's arm.(Systemic vs. Local ("Life over Limb"))

Edema

An abnormal turning inward of the lower eyelid, which causes the eyelashes to rub painfully against the eyeball.

Framework Example: A nurse observes a patient's lower eyelid is folded inward because of weakened eye muscles, causing the lashes to scratch the clear surface of the eye and creating an actual risk for permanent blindness that requires protective patching before an infection can form.(Actual vs. Potential (Problems over Risks))

Entropion

Redness of the skin caused by increased blood flow in the tiny blood vessels due to injury, inflammation, or infection.

Framework Example: A nurse notes bright red skin that is warm to the touch around a surgical wound caused by a localized bacterial infection, prompting the nurse to prioritize gathering wound cultures and starting antibiotics to prevent the infection from spreading into the blood.(Systemic vs. Local ("Life over Limb"))

Erythema

Skin scrapes, raw scratches, or surface damage caused by continuous rubbing, scratching, or exposure to moisture.

Framework Example: A nurse finds raw scratch marks and skin breakdown on an incontinent patient's skin caused by prolonged exposure to acidic urine, identifying an actual tissue injury that requires immediate application of a thick skin barrier ointment to prevent a potential deep infection.(Actual vs. Potential (Problems over Risks))

Excoriation

A special protractor device used to measure the exact angles and range of motion of a body joint.

Framework Example: A nurse uses a measuring tool to check a patient's knee joint angle after surgery to document if the joint movement is improving or worsening over time, utilizing these data trends to adjust the patient's physical therapy plan.(Trends vs. Isolated Findings)

Goniometer

An abnormal increase in muscle tension or stiffness, making the muscles tight and very hard to move or stretch.

Framework Example: A nurse notes a patient's arm muscles are rigidly stiff and resist stretching due to overactive nerve signals from a spinal cord injury, identifying an expected chronic condition that requires regular gentle stretching rather than emergency intervention.(Acute vs. Chronic)

Hypertonicity

An abnormal lack of muscle tension or strength, making the muscles feel floppy, weak, and loose.

Framework Example: A nurse notes a newborn baby's limbs are completely loose and floppy due to an unexpected lack of muscle tone from a genetic problem, prompting the nurse to immediately assess the infant's breathing and oxygen levels because weak muscles can cause the airway to collapse.(ABCs (Airway, Breathing, Circulation))

Hypotonicity

An area of skin or tissue that has become abnormally hard and firm, usually due to inflammation, infection, or a reaction to a skin test.

Framework Example: A nurse feels a firm, hardened bump under the skin exactly forty-eight hours after a tuberculosis skin injection caused by an immune response, recognizing this positive finding requires a priority referral for a chest x-ray to check for active lung disease.(Nursing Process (ADPIE))

Indurated

The clinical skill of carefully looking at, watching, and examining specific areas of the body using your eyes and proper lighting.

Framework Example: A nurse uses bright overhead lights to look closely at a patient's chest and sees unequal chest movement caused by broken ribs tearing the lung wall, identifying an acute breathing crisis that requires immediate needle decompression before completing the rest of the physical check.(ABCs (Airway, Breathing, Circulation))

Inspection

A yellow coloring of the skin, tissues, and whites of the eyes caused by a buildup of a yellow substance called bilirubin in the blood due to liver problems.

Framework Example: A nurse observes a patient's skin and eyes have turned bright yellow because a failing liver cannot filter out old blood waste, recognizing this systemic organ failure takes priority over a localized ankle sprain.(Systemic vs. Local ("Life over Limb"))

Jaundice

An exaggerated outward curvature of the upper back spine, often called a hunchback, commonly seen in older adults.

Framework Example: A nurse notes an older female patient has a severe outward curve of the upper back caused by bone thinning from osteoporosis, identifying a chronic stable spinal change that requires safe walking support to prevent future falls.(Acute vs. Chronic)

Kyphosis

An exaggerated inward curvature of the lower back spine, often called swayback, commonly seen during pregnancy.

Framework Example: A nurse notes a pregnant patient has a deep inward curve in her lower spine caused by the heavy forward weight of the growing baby shifting her center of gravity, recognizing this as an expected temporary change that requires education on comfortable seating rather than medical treatment.(Expected vs. Unexpected)

Lordosis

A dangerous, cancerous growth or tumor that can invade nearby tissues and spread throughout the body.

Framework Example: A nurse finds a hard, fixed lump under a patient's arm that is growing rapidly due to out-of-control cancerous cell division, recognizing that confirming this actual disease requires scheduling an immediate biopsy to start treatments before it spreads to potential vital organs.(Actual vs. Potential (Problems over Risks))

Malignancy

Abnormal swishing or blowing sounds heard when listening to the heart, caused by rough or backward blood flow through damaged heart valves.

Framework Example: A nurse hears a blowing sound between heartbeats caused by blood leaking backward through a torn heart valve, identifying an unstable drop in heart function that requires immediate vital sign checks and a call to the doctor if the patient has chest pain.(Stable vs. Unstable)

Murmurs

Involuntary, rapid, and rhythmic twitching or jerking movements of the eyes when looking to the side.

Framework Example: A nurse observes a patient's eyes twitching uncontrollably from side to side due to abnormal nerve signals in the inner ear or brain, recognizing this unexpected neurological sign requires an immediate safety check of the patient's balance to prevent a dangerous fall.(Expected vs. Unexpected)

Nystagmus

The sense of smell, which a nurse uses to detect specific bodily odors that can point to certain medical problems.

Framework Example: A nurse detects a sweet, fruity odor on the breath of an unconscious patient caused by a dangerous buildup of acidic chemical wastes from extreme blood sugar levels, identifying an acute metabolic emergency that requires an immediate insulin injection.(Stable vs. Unstable)

Olfaction

A severe difficulty in breathing that occurs when lying flat but gets better when a person sits up or stands.

Framework Example: A patient with heart failure gasps for air because fluid floods their lungs whenever they lie flat in bed, dictating that the nurse immediately raise the head of the bed to a high upright position to restore proper oxygen flow.(ABCs (Airway, Breathing, Circulation))

Orthopnea

A chronic bone disease that makes bones thin, weak, brittle, and highly likely to break from minor drops or bumps.

Framework Example: A nurse cares for an older patient whose bones have become incredibly fragile over time due to a rapid loss of calcium minerals, prompting the nurse to enforce strict fall prevention rules and clear clutter from the room to ensure the patient avoids a life-altering bone fracture.(Safety & Infection Control)

Osteoporosis

Damage to the inner ear or hearing nerves caused by toxic reactions to certain heavy medications.

Framework Example: A patient receiving strong intravenous antibiotics reports a sudden ringing in their ears and dizziness caused by the drug destroying delicate inner ear hair cells, identifying an acute adverse event that requires holding the next drug dose immediately to prevent permanent deafness.(Safety & Infection Control)

Ototoxicity

The clinical skill of using your hands and fingers to feel the body for temperature, swelling, tenderness, or lumps.

Framework Example: A nurse gently presses on a patient's lower right stomach area and notes the muscles freeze tight with severe pain caused by an inflamed, swollen appendix, identifying an actual surgical emergency that requires immediate bed rest and fasting before the organ can potentially burst.(Actual vs. Potential (Problems over Risks))

Palpation

The clinical skill of tapping specific areas of the body with your fingers to produce sounds that reveal the density and size of underlying organs.

Framework Example: A nurse taps over a patient's lower lung area and hears a dull, solid thud instead of a hollow sound because fluid has filled the lung tissue from severe pneumonia, identifying an acute breathing issue that requires immediate oxygen therapy setup.(ABCs (Airway, Breathing, Circulation))

Percussion

The wave-like muscle contractions that automatically push food, liquids, and waste forward through the digestive tract.

Framework Example: A nurse listens to a patient's stomach after surgery and hears zero bowel sounds because the wave-like muscle movements have temporarily paralyzed from anesthesia, identifying an unexpected complication that means the patient must remain fasting to avoid severe vomiting.(Expected vs. Unexpected)

Peristalsis

An acronym meaning the pupils of the eyes are equal, round, react to light, and adjust correctly when focusing on objects both near and far.

Framework Example: A nurse shines a light into an unconscious head injury patient's eyes and notes the left pupil stays wide and frozen due to high pressure squeezing the brain stem, identifying an acute neurological emergency that requires immediate notification of the surgical team.(Stable vs. Unstable)

PERRLA

Tiny, pinpoint-sized red or purple spots on the skin caused by minor bleeding from broken capillaries under the skin surface.

Framework Example: A nurse spots a cluster of tiny red dots across a patient's chest caused by a sudden, dangerous crash in blood-clotting cells, recognizing this systemic bleeding risk takes priority over a localized, minor bruise on the leg.(Systemic vs. Local ("Life over Limb"))

Petechiae

Small, abnormal growths of tissue that resemble tiny mushrooms sticking out from the lining of a mucous membrane, like inside the nose or colon.

Framework Example: A nurse reviews a patient's colon exam records and notes multiple tissue growths inside the large intestine that can turn into cancer over time, prioritizing the scheduling of an elective removal surgery to eliminate the problem before a potential malignant tumor develops.(Actual vs. Potential (Problems over Risks))

Polyps

An abnormal drooping or sagging of the upper eyelid over the eye, which can block vision and point to nerve damage.

Framework Example: A nurse notes a patient's left upper eyelid is suddenly sagging deeply due to a dangerous blood clot blocking nerve signals in the brain, identifying an unstable stroke event that requires launching an immediate emergency response team.(Stable vs. Unstable)

Ptosis

An abnormal sideways or S-shaped curvature of the spine that typically develops during growth spurts before puberty.

Framework Example: A nurse screens a young student and finds a sideways curve in the spine caused by uneven bone growth, identifying a chronic structural condition that requires a routine specialist referral rather than immediate emergency care.(Acute vs. Chronic)

Scoliosis

An abnormal narrowing or tightening of a body passage, blood vessel, or heart valve opening that reduces normal flow.

Framework Example: A nurse listens to a patient's heart and hears a rough scraping sound caused by a heart valve that has become tight and stiff from calcium buildup, identifying an unstable reduction in blood flow that requires an immediate check of the patient's blood pressure and oxygen levels.(Stable vs. Unstable)

Stenosis

Stretch marks, which are shiny silver, pink, or purple lines on the skin caused by rapid stretching of the tissue during weight gain or pregnancy.

Framework Example: A nurse notes silver lines across a pregnant patient's expanding stomach caused by the natural tearing of deep elastic skin layers, recognizing this as an expected physical finding that requires simple skin lotion education rather than any medical treatment.(Expected vs. Unexpected)

Striae

Fainting or a temporary loss of consciousness caused by a sudden, temporary drop in blood flow to the brain.

Framework Example: A patient suddenly passes out and falls to the floor because their blood pressure plummeted instantly upon standing, dictating that the nurse immediately elevate the patient's legs and check their pulse to restore oxygen flow to the brain before performing any other tasks.(ABCs (Airway, Breathing, Circulation))

Syncope

A continuous vibrating or buzzing sensation felt with the palm of your hand over an abnormal blood vessel or heart valve.

Framework Example: A nurse feels a heavy purring vibration over a patient's hemodialysis arm graft caused by high-pressure blood rushing through the surgical connection, recognizing this is an expected normal sign that proves the blood line is open and working correctly.(Expected vs. Unexpected)

Thrill

The natural elasticity of the skin that shows how hydrated a person is, tested by pinching the skin to see how fast it snaps back flat.

Framework Example: A nurse pinches the skin over an elderly patient's chest bone and notes it stays tented upright due to severe dehydration from prolonged vomiting, identifying an actual fluid volume deficit that requires prioritizing intravenous fluid setup over routine comfort care.(Actual vs. Potential (Problems over Risks))

Turgor

An abnormal extra heart sound, often called an S3 sound, that sounds like a galloping horse and is caused by fluid slamming into a stretched-out heart chamber.

Framework Example: A nurse hears a low-pitched extra sound right after the regular heartbeat caused by fluid overloading a failing heart muscle, identifying an unstable cardiac state that requires immediate administration of fluid-draining medications before a breathing crisis develops.(Stable vs. Unstable)

Ventricular gallop

Tremors or vibrations felt on the patient's chest wall with the palms of your hands while the patient speaks or says specific words.

Framework Example: A nurse feels highly intense, heavy vibrations over a patient's right lung while they speak because thick fluid from a severe infection is conducting sound waves directly through the tissue, identifying an actual lung consolidation problem that requires immediate chest physiotherapy and oxygen monitoring.(Actual vs. Potential (Problems over Risks))

Vocal or tactile fremitus