Physical Assessment Study Flashcards

Comprehensive vocabulary and concept flashcards covering physical assessment techniques, vital signs, anatomy markers, and diagnostic scales based on the lecture transcript.

Caryl Morgan MSN, RN

The professional credited with the creation of the Physical Assessment lecture materials.

Purpose of Physical Exam

To obtain baseline data, identify nursing problems, and provide screening.

Comprehensive Physical Assessment

Consists of an interview plus a complete head-to-toe examination.

Focused Physical Assessment

An assessment that is focused on a specific presenting problem.

System-specific Physical Assessment

An assessment limited to one specific body system.

Ongoing Physical Assessment

Performed as needed to assess status and evaluate client outcomes.

Preliminary Actions

Identify yourself, identify patient using $2$ identifiers, explain procedure, gather supplies, perform hand hygiene, and provide for privacy.

Objective Data

Information that is observed or measured, such as a WBC count of $9.7\,g/dL$.

Subjective Data

Information stated or reported by the patient.

SPICES

An acronym used for assessment of the older adult concerning physical ability and activities of daily living (ADLs).

60 Second Situational Assessment

A survey of ABC (airway, breathing, circulation) without touching the patient, including tubes, lines, respiratory equipment, and environmental safety.

Glasgow Coma Scale (GCS)

A scale used to assess mental status based on best eye response ($1-4$), best verbal response ($1-5$), and best motor response ($1-6$).

Hypothalamic Integrator

The center in the brain that controls core body temperature.

Radiation

Loss of heat through electromagnetic waves emitting from surfaces warmer than the surrounding air.

Convection

Transfer of heat through currents of air or water.

Evaporation

Water converted to vapor and lost from the skin as perspiration or mucous membranes through breath.

Conduction

Transfer of heat from a warm to a cool surface by direct contact.

Pyrexia

A fever condition where body temperature is high, greater than $100\,^{\circ}F$ oral or $101\,^{\circ}F$ rectal.

Hyperpyrexia

An abnormally high body temperature or fever greater than $105.8\,^{\circ}F$.

Heat Stroke Characteristics

Hot/dry skin, absence of sweating, seizures, delirium, and rapid shallow respirations.

Mild Hypothermia

Body temperature between $89.6\,^{\circ}F$ and $96.67\,^{\circ}F$; characterized by fatigue, shivering, and cold diuresis.

Moderate Hypothermia

Body temperature between $82.4\,^{\circ}F$ and $89.5\,^{\circ}F$; characterized by no shivering, decreased LOC, and cyanotic color.

Severe Hypothermia

Body temperature less than $82.4\,^{\circ}F$; characterized by ventricular fibrillation, dilated pupils, and no respirations.

Pulse Volume Grade 1

Weak or thready pulse that is barely felt and easily obliterated.

Pulse Volume Grade 3

Bounding or full pulse that is easily felt with little pressure and not easily obliterated.

Pallor

Paleness of skin compared with another part of the body, indicating inadequate circulation.

Cyanosis

A bluish or grayish discoloration of the skin due to excessive $CO_2$ and deficient oxygen.

Normal Adult Respiratory Rate

$12-20$ respirations per minute.

Hyperventilation

Rapid and deep breathing resulting in excess loss of $CO_2$ (hypocapnea).

Normal $O_2$ Saturation

$95\%-100\%$.

Hemoglobin (Hgb)

A primary protein of erythrocytes that carries $O_2$ to cells; normal range is $13-18\,mg/dL$.

Stage I Hypertension

Systolic $130-139\,mmHg$ or Diastolic $80-90\,mmHg$.

Hypertensive Crisis

Systolic $>180\,mmHg$ and/or Diastolic $>120\,mmHg$.

FLACC Scale

A behavioral observation pain rating scale assessing Face, Legs, Activity, Cry, and Consolability.

COLDERR

An acronym for evaluating pain: Character, Onset, Location, Duration, Exacerbation, Relief, Radiation.

Braden Scale

A tool for predicting pressure sore risk based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Pitting Edema Grade 3+

$4-6\,mm$ depth with a $10-12$ second rebound.

Macule

Flat, nonpalpable change in skin color, usually smaller than $1\,cm$.

Vesicle

A small blisterlike raised area of the skin containing serous fluid, up to $1\,cm$ in diameter.

Clubbing

A nail condition where the angle is $>180^{\circ}$, often associated with chronic hypoxia.

PERRLA

Pupils Equal, Round, Reactive to Light and Accommodation.

Tanner Stages

A five-stage system used to describe the development of secondary sexual characteristics in males and females.

Wheeze

High-pitched continuous musical sounds usually heard on expiration caused by bronchospasm or asthma.

Rhonchi

Low-pitched continuous sounds caused by secretions in the large airways.

Crackles (Rales)

Discontinuous popping or bubbling sounds heard on inspiration caused by fluid in the alveoli.

Stridor

A piercing, high-pitched sound heard primarily during inspiration.

Stetors

Labored breathing that produces a snoring sound.

Cheyne-Stokes

A regular cycle where the rate and depth of breathing increase, then decrease until apnea (about $20$ seconds) occurs.

Biot's Respiration

Periods of normal breathing followed by a varying period of apnea ($10$ seconds to $1$ minute).

Kyphosis

An exaggerated outward curvature of the thoracic spine.

Lordosis

An exaggerated inward curvature of the lumbar spine.

Romberg's Test

A neurological/musculoskeletal test for balance and motor nerve function.

Cranial Nerve I (Olfactory)

A sensory nerve tested using a Sniff Test with items like alcohol under each nare.

Cranial Nerve VII (Facial)

A both sensory and motor nerve tested by having the patient smile, frown, puff cheeks, and testing taste on the anterior tongue.

Reflex Grading 2+

Normal response with visible muscle twitch and movement of the limb.

Abdominal Assessment Sequence

The specific order of Inspect, Auscultate, Percuss, then Palpate (Look, Listen, then Feel).