Physical Exam and Nursing Assessment Lecture Notes

Flashcards covering primary nursing assessment techniques, vital signs, physical exam steps, and clinical terminology based on lecture notes.

Baseline Data

Information about the patient’s physical status and functional abilities that serves as a comparison as the patient’s health status changes.

Comprehensive Physical Assessment

Includes a situational survey, general survey, health history interview, and a complete head-to-toe examination of every body system.

Focused Physical Assessment

An assessment concentrated on a presenting problem, such as performing a thorough GI and GU assessment for severe right-sided abdominal pain.

System-specific Physical Assessment

An assessment limited to one specific body system, such as a cardiac or respiratory exam.

Ongoing Physical Assessment

Performed as needed to evaluate client outcomes and look for trends, such as neurological exams conducted every hour for a head injury.

Primary Subjective Data

Information provided directly by the client that can only be verified by that person, such as itching, pain, or anxiety.

Secondary Subjective Data

Information said by someone other than the client, such as a mother stating that her child is sick.

Primary Objective Data

Data obtained by the nurse through observation and examination, such as a blood pressure reading or observing a client grimacing.

Secondary Objective Data

Data observed by someone other than the nurse, such as a CNA reporting that a client is vomiting.

Constant Data

Information that does not change over time, such as blood type, race, date of birth, and sex.

Variable Data

Information that changes, such as vital signs, pain level, height, and weight.

Modifiable Risk Factors

Aspects of health that a person can control, including diet, exercise, smoking, and stress.

Non-modifiable Risk Factors

Aspects of health that cannot be controlled, such as age, sex, race, and genetics.

Olfactory Assessment

The use of the sense of smell to gather data during a clinical assessment.

Inspection

The use of sight to gather objective data, often aided by adequate lighting and a penlight.

Direct Auscultation

Listening to body sounds without the use of an instrument, such as hearing wheezing without a stethoscope.

Indirect Auscultation

Listening to body sounds with the help of a stethoscope.

Palpation

The use of touch to assess temperature, skin texture, moisture, anatomical landmarks, edema, masses, or tenderness.

Dorsum of the hand

The part of the hand used specifically for temperature determination during palpation.

Fingertips

The part of the hand used for tactile discrimination during palpation.

Percussion

Tapping a finger on a patient's body to produce vibrations and sounds used to determine the location, size, and density of underlying structures.

Direct Percussion

Tapping fingers directly over an area, such as the sinus areas, to check for tenderness.

Indirect Percussion

Striking one middle finger on top of the other middle finger to elicit sound over structures like the bladder or lungs.

SPICES Acronym

A tool to remember common problems in the elderly: Sleep disorders, Problems with eating/feeding, Incontinence, Confusion, Evidence of falls, and Skin breakdown.

Cultural Safety

Creating safe spaces for patient interaction without judgment, racialization, or discrimination.

60 Second Situational Assessment

A rapid survey checking ABC (Airway, Breathing, Circulation), tubes/lines, respiratory equipment, and patient safety without touching the patient.

General Survey

An overall impression of the patient including appearance, behavior, body type, speech, and mental state.

Expressive Aphasia

A condition where the patient cannot find the right words to say but may understand speech well; also called output aphasia.

Receptive Aphasia

A condition where the patient can say words but they do not make complete sense, and they have trouble understanding speech.

Glasgow Coma Scale (GCS)

An assessment tool measuring three categories: Eyes, Verbal, and Motor responses.

Normal Adult BMI Range

The expected finding for an adult is a body mass index of $18.5 - 24.9$.

Morbid Obesity

A BMI classification for values greater than $40$.

Anxiety Signs and Symptoms

Restless feeling, tachycardia, tachypnea, trouble sleeping, and difficulty concentrating.

Core Temperature

The internal temperature regulated by the hypothalamus, typically measured rectally and usually $1$ to $2^{\circ}F$ higher than surface temperature.

Radiation

The loss of body heat through the skin to the surrounding air, accounting for approximately $50\%$ of body heat loss.

Convection

Heat loss or gain via air currents, such as using a fan to reduce fever or a warm bath to raise temperature.

Hyperthermia

A core body temperature rising above the normal range of $99.8^{\circ}F$.

Hyperpyrexia

A fever equal to or greater than $105.8^{\circ}F$, representing a controlled response where the hypothalamic set point is elevated.

Heat Stroke

A severe hyperthermia clinical state with a core temperature above $103 - 106^{\circ}F$ where sweating may stop and compensation fails.

Hypothermia

A core body temperature rectal reading below $95^{\circ}F$, often characterized by shivering (initially) and slowed metabolic processes.

Allen Test

A procedure involving the occlusion of the radial and ulnar arteries to assess if one artery is healthy enough to supply blood to the hand independently.

Homan's Sign

The assessment for deep vein thrombosis by having the patient dorsiflex their foot to check for calf pain.

Apical Pulse (PMI)

Located at the $5^{th}$ intercostal space at the left midclavicular line for adults; the most accurate pulse location.

Cardiac Output

The volume of blood the heart beats per minute, calculated as $Stroke\,Volume \times Pulse\,Rate$.

Pulse Deficit

The difference between the apical pulse rate and the radial pulse rate.

Bradycardia

A heart rate less than $60\,Beats\,per\,Minute$.

Tachycardia

A heart rate greater than $100\,Beats\,per\,Minute$.

Capillary Refill Test (CRT)

A test of peripheral perfusion where the normal finding is a return of color in less than $3\,seconds$.

Pulse Volume Scale 1

A pulse that is weak or thready, barely felt, and easily obliterated by pressure.

Pulse Volume Scale 3

A pulse that is bounding or full, easily felt with little pressure, and not easily obliterated.

Cyanosis

A bluish or grayish skin discoloration caused by excessive carbon dioxide and deficient oxygen in the blood.

Eupnea

Normal, quiet, unlabored breathing at rest.

Orthopnea

The inability to breathe when in a horizontal position.

Bradypnea

Abnormally slow breathing, defined as less than $12\,breaths\,per\,minute$.

Kussmaul Respirations

Deep, rapid, large-volume breathing often characteristic of diabetic ketoacidosis.

Pulse Oximetry

A noninvasive method reflecting the percentage of hemoglobin molecules carrying oxygen, with a normal value of $95\% - 100\%$.

Mean Arterial Pressure (MAP)

A calculation of arterial pressure determined by $\frac{Systolic + (2 \times Diastolic)}{3}$, with a normal range of $70 - 100$.

Orthostatic Hypotension

A sudden drop in blood pressure where there is a $20\,mmHg$ or greater drop in systolic or a $10\,mmHg$ or greater drop in diastolic pressure within $3\,minutes$ of standing.

FLACC Scale

A pain assessment tool used for children or adults with developmental delays, measuring Face, Legs, Activity, Cry, and Consolability.

Braden Scale

A tool used to predict pressure injury risk; categories include Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction/Shearing.

Tenting

A condition where skin takes several seconds to return to its original position after being pinched, indicating dehydration.

Pitting Edema 4+ stage

Indication of edema with a depth of $8\,mm$ (approximately $\frac{1}{4}\,inch$).

Macule

A flat skin lesion, such as a freckle or petechiae.

Vesicle

A small, thin, translucent mass filled with serous fluid or blood, such as a blister or shingles.

Clubbing

A nail plate angle of $180^{\circ}$ or more, associated with long-term hypoxic states like COPD.

Weber Test

A bone conduction hearing test where a vibrating tuning fork is placed on the center of the head to check for equal sensation in both ears.

Rhinne Test

A hearing test that compares air conduction to bone conduction; normally air conduction is twice as long.

PERRLA

An acronym for eye assessment meaning: Pupils Equal, Round, and Reactive to Light and Accommodation.

Anicteric Sclera

White sclera that is without yellowing.

Ptosis

A drooping of the eyelid.

Gynecomastia

The enlargement of breast tissue in male individuals.

Kyphosis

An excessive outward curvature of the thoracic spine.

Bronchial Breath Sounds

Loud, high-pitched tubular sounds heard best over the trachea where expiration is longer than inspiration.

Vesicular Breath Sounds

Soft, low-pitched, breezy sounds heard over the lung fields with a long inspiratory phase and short expiratory phase.

Crackles (Rales)

Adventitious discontinuous popping or bubbling sounds heard on inspiration, caused by air passing through fluid or mucus.

Stridor

A piercing, high-pitched sound heard primarily during inspiration, indicating an obstructed airway.

S1 Heart Sound

A dull, low-pitched sound caused by the closure of the mitral and tricuspid valves, best heard at the apex (LUB).

S2 Heart Sound

A higher-pitched sound caused by the closure of the aortic and pulmonic valves (DUP).

Bruit

A blowing or swishing sound heard through a stethoscope, indicating turbulent blood flow.

Thrill

A continuous palpable vibration sensation, similar to a purring cat, felt over an area of turbulent blood flow.

Normoactive Bowel Sounds

Irregular gurgles or clicks occurring every $5$ to $15\,seconds$ (or $5$ to $30\,times\,per\,minute$) in the average adult.

Oliguria

A diminished urine output defined as $100 - 400\,mL$ per $24$-hour period.

Anuria

The absence of urine, defined as less than $100\,mL$ per $24$-hour period.

Romberg’s Test

A test of motor/cerebellar function where the patient stands with feet together and eyes closed to observe for swaying.

Proprioception

The body's ability to sense its own position and movement.