Physical Assessment Unit 1 Test

Dimensions of wellness

Helps think of the patient as a whole self

Spiritual dimension of wellness

Spiritual beliefs

Not necessarily religious

Environmental dimension of wellness

Includes food security, access to clean water, transportation, etc.

Intellectual dimension of wellness

Are they intellectually stimulated?

Older adults struggle with this

Occupational dimension of wellness

Are they engage and satisfied?

Do they have the resources to succeed?

Comprehensive assessment

Baseline data

Full history/physical

Looking at all body systems

Typically during initial assessment

Initial assessment

Establish a complete database for problem identification

Prioritize figuring out why the person is there

Then, the rest of the comprehensive assessment

Focused assessment

Get data about a problem that has already been identified

s/s, timeline, any remedies

Quick priority assessment (commonly used in ER)

Short and prioritized

Flag existing problems/risks

Emergency assessment when is it used?

Rolling out of the ambulance

Emergency assessment

What’s going to kill them first?

Prioritize life-threatening needs

Triage assessment

Determine severity

Prioritize emergent needs

Time-lapsed assessment (aka re-assessment)

Reassessment of the condition compared to initial encounter

May be comprehensive or focused

Helps determine if nursing interventions are appropriate

Four cardinal techniques of assessment (in order)

Look (examine)

Feel (palpate)

Percuss

Listen (ausculate)

Types of assessment data

Subjective and objective

Subjective assessment data

“Stated” by the patient

Cannot be measured

Objective assessment data

“Observed” by the nurse

Can be measured/analyzed

OLDCARTS

Onset

Location

Duration

Characteristics

Alleviating/aggravating

Relieving factors

Treatments

Severity

General survey (not used in emergency assessment)

Assess apparent state of health

History of present illness (HPI)

Elaborates on the chief complaint using OLDCARTS

Freud’s oral stage

Birth-12mo

Focused on mouth (sucking)

Freud’s anal stage

1-3yo

Focused on anus (elimination)

Freud’s phallic stage

3-6yo

Focused on genitals

Freud’s latency stage

7-11yo

Repressed sexual impulses

Social skills develop

Freud’s genital stage

Puberty-onward

Sexual reawakening

Focused on outside the family

Piaget sensorimotor stage

0-2yo

Learn through the senses

Piaget preoperational stage

2-7yo

Develop language and understand symbols

Think egocentrically

Piaget concrete operational stage

7-11yo

Think logically and understand conversation

Piaget formal operational stage

12+yo

Develop abstract and hypothetical thinking

Morality and the future

Instrumental activities of daily living (IADLs)

Using the phone, doing laundry, driving/using transportation, taking medications, etc.

Ethnocentrism

Evaluation of other cultures from one’s own culture

Cultural humility

Reflection about assumptions and being receptive to other’s experiences

Why is cultural humility important?

Involves recognizing power imbalances between nurse/patient

Culture bound syndrome

Illnesses defined by a particular culture but not recognized in western medicine

Ex. mal de ojo

Why is spiritual assessment not always adequate?

Patients can feel like it will affect their healthcare

When is spiritual assessment appropriate?

Death and dying

Transduction in pain

Activation of pain receptors

Transmission in pain

Pain sensation from are of injury to spinal cord higher centers

Pain perception in pain

Person’s interpretation of the pain

Pain modulation in pain

Inhibiting/modifying the sensation of pain

Ex. avoiding things that make it worse

Types of pain scales depending on what we want to know

Quantitative

Qualitative

Adult nonverbal pain scale

0-2

Based on observations

Comfort pain scale

1-5

Based on behavioral cues

Used mostly in children

CRIES pain scale

0-2

Based on observations

Great for infants

FLACC pain scale

0-2

Face

Legs

Activity

Cry

Consolability

Wong-baker FACES pain scale

0-5

Helps determine pain based on the faces’ expressions

Great for children and people who speak other languages

WILDA approach

Helps assess pain as a whole

Ex. Descriptions, intensity, location

Factors that affect the skin

Hydration

Circulation

Nutrition

External force

Edema/thickness

Non-pitting

Pitting

Ranking scale for pitting edema

Based on the mm of the finger identation

Adequate peripheral perfusion

Within 3 seconds

Tinea capitis

Scalp yeast infection (craddle cap)

Papule

Elevated, raised, superficial

Ex. moles

Macule

Flat

Ex. Freckles, birthmarks, petechia

Vesicle/bulla

Elevated, fluid-filled, palpable

Ex. Blisters, herpes

Pustule

Elevated, pus-filled, palpable

Ex. Acne, folliculitis

Wheal

Elevated, localized edema (just swelling)

Ex. Insect bites, hives

Nodule

Just trauma

Cyst

Deeper, can be filled with anything

Scales

Flaking of the skin

Ex. Dandruff

Crust

Elevated, rough texture

Ex. Dried exudate impetigo

Scar

Fibrous tissue of a healed injury

Keloid

Raised elevated scar

Overgrowth of collagen

Angioma

Papule filled with blood

Purpura

More concentrated petechiae

Think: Blood clot!!

Ecchymosis

Bruising

Ischemia

Compromised blood flow to the area

Ex. Pressure ulcers

Where do pressure ulcers happen?

Any bony prominences/areas of high friction

ABCD rule for skin cancer

Asymmetry

Border irregularity

Color

Diameter

Basal cell carcinoma

Most common type of skin cancer

Squamous cell carcinoma

Second most common type of skin cancer

Melanoma

Deadliest form of skin cancer

Biggest skin cancer risk factor

Light skin/eyes/hair

Personal/family history

Older age

Important consideration of breast examination

Axillary tail of Spence HAS to be included in the examination

Gynecomastia

Male breasts that temporarily enlarge during adolescence

Signs for concern in breast cancer examination

Inverted nipple

Rash/discoloration

Edema

Change in shape/dimpling

Fibroadenoma

Puberty and early adulthood

Very mobile

Non-tender

Cysts (breasts)

Adulthood (30-50)

Mobile

Often tender

Breast cancer

Adulthood to late adulthood (30-90)

Irregular bumps!

Hard

NON-mobile

Non-tender

African american breast cancer risk

Lower incidence

Higher death rate

Mammogram schedule 40-44yo

Can choose to do annual exams

Mammogram schedule 45-54yo

Should get it every year

Mammogram schedule 55yo+

Every 2 years or continue yearly

What type of self-examination is best for bigger chested women?

Lying down with an arm up

What is the predominant symptom of problems in the scrotum?

Dragging, heavy feeling

Cryptorchidism

Undescended testicle

Why should men perform testicular examinations in the shower?

Warm water relaxes the scrotal sac

Testicular cancer risks

Age 15-40

White males 4x more likely

Undescended testicles

Tendon

Binds muscle to bone

Ligament

Binds bone to bone