Physical Assessment Study Flashcards

Purpose and Types of Physical Assessment

• Purpose of a Physical Examination:     * Establish baseline data for the patient.     * Identify actual or potential nursing problems.     * Perform screening for health risks.

• Types of Physical Assessments:     * Comprehensive Assessment: Involves a detailed interview combined with a complete head-to-toe examination.     * Focused Assessment: Specifically targets the presenting problem or a particular complaint.     * System-specific Assessment: Limited to the examination of one body system (e.g., just the cardiovascular system).     * Ongoing Assessment: Performed as needed to assess the patient's status and evaluate the effectiveness of client outcomes.

• Approaches to Assessment:     * Head to Toe: A systematic progression from the top of the body to the bottom.     * Body Systems: Organizing the assessment by physiological systems.

Preliminary Actions and Data Principles

• Preliminary Actions before Assessment:     * Identify yourself to the patient.     * Identify the patient using at least $2$ unique identifiers.     * Explain the procedure to the patient.     * Gather all necessary supplies.     * Perform hand hygiene.     * Provide for patient privacy.     * Perform additional preparatory actions as required by the setting.

• Gathering Data:     * Objective Data: Information that is observed (e.g., laboratory results like $WBC = 9.7\,g/dL$).     * Subjective Data: Information that is stated by the patient (self-reported).     * Constant Data: Information that does not change (e.g., date of birth).     * Variable Data: Information that fluctuates (e.g., blood pressure, temperature).

Age-Related Modifications for Physical Examination

• Infants:     * Allow parents to hold the infant during the exam.     * Prioritize safety at all times.

• Toddlers:     * Allow them to explore the environment and/or sit on the parent’s lap.     * Perform invasive procedures (e.g., looking in ears) last.     * Offer simple choices to increase cooperation.     * Use praise frequently.

• Preschoolers:     * Use a doll or clinical toy for demonstration of procedures.     * The child may still prefer parental contact.     * Allow the child to "help" with the examination equipment.

• School-age Children:     * Show approval and focus on developing rapport.     * Allow for independence.     * Use the exam to teach them about how their body works.

• Adolescents:     * Provide maximum privacy.     * Address concerns about whether they are “normal.”     * Use the examination as a teaching tool for healthy lifestyles.     * Specifically screen for suicide risk.

• Young/Middle Adults:     * Modify the approach based on the presence of acute or chronic illness.

• Older Adults:     * Positioning adjustments may be needed due to mobility issues (e.g., arthritis).     * Adapt the exam to account for changes in vision and hearing.     * Assess for changes in physical ability and the ability to perform Activities of Daily Living (ADLs).     * Provide rest periods during the exam.     * Utilize the "SPICES" framework for assessing older adults.

Cultural Evaluation and Situational Assessment

• Cultural Evaluation Prior to Exam:     * Respect differences in communication styles and health beliefs.     * Understand family dynamics and identify barriers to care.     * Ensure "Cultural Safety" for the patient.

• 60-Second Situational Assessment/Survey:     * ABC (Airway, Breathing, Circulation): Observe without touching the patient first.     * Tubes and Lines: Check for any intravenous lines, foley catheters, or drain tubes.     * Respiratory Equipment: Verify oxygen settings or ventilators.     * Safety Surveys: Perform both a Patient Safety Survey and an Environmental Safety check.     * Sensory Input: Actively use all senses to observe the environment.

General Survey and Mental Status

• Components of General Survey:     * Appearance/Behavior: Evaluate age, sex, gender, race, facial expression, mood, and affect.     * Physicality: Assess body type, posture, gait, and sensory deficits.     * Social/Maintenance: Observe dressing, grooming, and hygiene.     * Measurements: Height, Weight, and Body Mass Index (BMI).     * Vision/Vital Signs: Check vision as needed and record all vital signs.

• Glasgow Coma Scale (GCS):     * Best Eye Response (E):         * $4$: Eyes opening spontaneously.         * $3$: Eye opening to speech.         * $2$: Eye opening in response to pain.         * $1$: No eye opening.     * Best Verbal Response (V):         * $5$: Oriented.         * $4$: Confused.         * $3$: Inappropriate words.         * $2$: Incomprehensible sounds.         * $1$: None.     * Best Motor Response (M):         * $6$: Obeys commands.         * $5$: Localizes to pain.         * $4$: Withdraws from pain.         * $3$: Flexion in response to pain (decorticate).         * $2$: Extension to pain (decerebrate).         * $1$: No motor response.

Vital Signs: Body Temperature and Thermoregulation

• Hypothalamic Integrator: The center that controls core temperature, containing both heat and cold sensors.

• Core Temperature Settings: Normal is roughly $37^{\circ}C$ ($98.6^{\circ}F$).

• Heat Production and Conservation:     * Production: Basal metabolism, muscle contraction, and increased metabolic rate.     * Conservation: Shivering and vasoconstriction.

• Mechanisms of Heat Loss:     * Radiation: Loss of heat through electromagnetic waves emitting from surfaces warmer than surrounding air.     * Convection: Transfer of heat through currents of air or water.     * Evaporation: Conversion of water to vapor lost from skin (perspiration) or mucous membranes (breath).     * Conduction: Transfer of heat from a warm to a cool surface by direct contact.

• Temperature Variances:     * Pyrexia (Fever): High body temperature where oral is $> 100^{\circ}F$ or rectal is $> 101^{\circ}F$. Caused by pyrogens (e.g., bacteria) inducing prostaglandins that reset the hypothalamus.     * Hyperpyrexia: Abnormally high fever greater than $105.8^{\circ}F$ ($41^{\circ}C$). Irreversible cell damage and death occur at temperatures $> 45^{\circ}C$ ($113^{\circ}F$).     * Hypothermia:         * Mild: $89.6^{\circ}F$ to $96.67^{\circ}F$. Symptoms: Shivering, increased HR/RR, fatigue, confusion.         * Moderate: $82.4^{\circ}F$ to $89.5^{\circ}F$. Symptoms: No shivering, decreased HR/RR/BP, pale/cyanotic color.         * Severe: $< 82.4^{\circ}F$. Symptoms: Absent pulse/respirations, ventricular fibrillation, dilated pupils, coma.

• Thermoregulation Conditions:     * Heat Exhaustion: Characterized by dizziness, nausea, fatigue, hyperventilation, cold/clammy skin, and diaphoresis.     * Heat Stroke: Characterized by hot/dry skin, absence of sweating, seizures, delirium, and organ failure.

Vital Signs: Pulse and Hemodynamics

• Pulse Locations: Temporal, Carotid, Brachial, Radial, Ulnar, Femoral, Popliteal, Posterior tibial, and Dorsalis pedis.

• Apical Pulse Landmarks:     * Adults: Located at the 5th intercostal space at the left midclavicular line.     * Children (ages 4-6): Midclavicular line.     * Infants (before age 4): Lateral to the midclavicular line.

• Pulse Terminology:     * Cardiac Output: Volume of blood pumped by the heart per minute.     * PMI: Point of Maximal Impulse.     * Pulse Deficit: Difference between apical and radial pulse rates.     * Bradycardia: Rate $< 60\,bpm$.     * Tachycardia: Rate $> 100\,bpm$.     * Dysrhythmia: Irregular heart rhythm.

• Pulse Volume Scale:     * $0$ = Absent (cannot be felt).     * $1$ = Weak or thready (easily obliterated).     * $2$ = Normal (easily palpated).     * $3$ = Bounding or full (not easily obliterated).

• Inadequate Circulation Indicators:     * Pallor: Paleness of skin.     * Cyanosis: Bluish/grayish skin due to excessive $CO_2$ and deficient $O_2$.     * Capillary Refill Test (CRT): Assessment of peripheral perfusion.

Vital Signs: Respirations and Oxygenation

• Normal Respiratory Rates:     * Newborns: $44\,bpm$ (can be up to $60$ when crying).     * Infants: $20-40\,bpm$.     * Children (1-7 years): $18-30\,bpm$.     * Adults: $12-20\,bpm$.

• Ventilation and Patterns:     * Hyperventilation: Rapid/deep breathing resulting in hypocapnia (low $CO_2$).     * Hypoventilation: Decreased rate/depth of breathing resulting in $CO_2$ retention.     * Eupnea: Normal breathing ($12-18\,bpm$).     * Bradypnea: Slower than normal ($< 10\,bpm$).     * Tachypnea: Rapid, shallow ($> 24\,bpm$).     * Apnea: Cessation of breathing.     * Cheyne-Stokes: Gradual increase then decrease in depth, followed by apnea.     * Biot's: Irregular periods of apnea alternating with normal breaths.     * Kussmaul’s: Increased rate and depth caused by Diabetic Ketoacidosis (DKA).

• Oxygen Saturation ($O_2$ Sat): Normal range is $95\%-100\%$.

Vital Signs: Blood Pressure and Hemoglobin

• BP Classifications (Adult):     * Normal: $< 120\,mmHg$ systolic AND $< 80\,mmHg$ diastolic.     * Elevated: $120-129\,mmHg$ systolic AND $< 80\,mmHg$ diastolic.     * Stage I Hypertension: $130-139\,mmHg$ systolic OR $80-89\,mmHg$ diastolic.     * Stage II Hypertension: $\ge 140\,mmHg$ systolic OR $\ge 90\,mmHg$ diastolic.     * Hypertensive Crisis: $> 180\,mmHg$ systolic AND/OR $> 120\,mmHg$ diastolic.

• Hemoglobin ($Hgb$):     * Normal Range: $13-18\,mg/dL$.     * Anemia Severity:         * Critical: $< 7\,mg/dL$.         * Severe: $< 7\,mg/dL$.         * Moderate: $7-10\,mg/dL$.         * Mild: $10-12\,mg/dL$.     * Treatments: Correct underlying cause, stop blood loss, iron, erythropoietin, or blood transfusion.

Pain Assessment: The Fifth Vital Sign

• Scales:     * Numeric Pain Rating Scale: $0-10$.     * Wong-Baker FACES: Used for children or those with language barriers.     * FLACC Scale: Behavioral observation (Face, Legs, Activity, Cry, Consolability), each scored $0-2$ for a total of $0-10$.

• Mnemonics for Subjective Data:     * COLDERR: Character, Onset, Location, Duration, Exacerbation, Relief, Radiation.     * OPQRST: Onset, Provocation/Palliation, Quality, Region, Severity, Timing.

• Objective Signs of Pain: Increased BP/HR/RR, pallor, diaphoresis, pupil dilation, moaning, or guarding.

Integumentary System Assessment

• Inspection: Color, moisture, lesions, edema, vascular lesions, drainage, and scars.

• Palpation: Temperature, contour, consistency, turgor, and pain.

• Primary Lesions:     * Macule: Flat, nonpalpable color change, $< 1\,cm$ (e.g., freckle).     * Papule: Palpable solid raised lesion, $< 1\,cm$ (e.g., mole).     * Nodule: Solid elevated lesion, deeper than papule (e.g., fibroma).     * Vesicle: Raised area with serous fluid, up to $1\,cm$ (e.g., shingles).     * Bulla: Fluid-filled blister, $> 1\,cm$ (e.g., burn).     * Pustule: Elevation containing pus (e.g., acne).     * Wheal: Transient elevation from dermal edema (e.g., hives).     * Plaque: Solid raised lesion, $> 1\,cm$ (e.g., psoriasis).     * Cyst: Closed sac with semisolid or liquid material.

• Secondary Lesions:     * Scale: Dry exfoliation of dead epidermis.     * Crust: A scab of dry serum, blood, or pus.     * Ulcer: Open sore extending to the dermis.     * Lichenification: Thickening/hardening from scratching.     * Excoriation: Linear scratch marks.     * Fissure: Slit or crack extending into dermis.

• Braden Scale: Evaluates risk for pressure sores using Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear.

• Pitting Edema Scale:     * 1+: $2\,mm$ (disappears immediately).     * 2+: $4\,mm$ (few second rebound).     * 3+: $6\,mm$ ($10-12$ second rebound).     * 4+: $8\,mm$ ($> 20$ second rebound).

Head, Ears, Eyes, Nose, and Throat (HEENT)

• Eyes:     * PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation.     * Pupil Size: Normal is $3-7\,mm$.     * EOM: Extraocular Movements (6 cardinal fields of gaze).

• Nose: Assess for symmetry; check for a deviated nasal septum.

• Mouth: Inspect lips, tongue, and throat for ulcers or abnormalities.

• Nails: Normal angle is $160^{\circ}$. Clubbing is an angle $> 180^{\circ}$.

Respiratory and Cardiovascular Systems

• Lung Sounds:     * Bronchial: Heard over the trachea.     * Bronchovesicular: Heard over the mainstem bronchi.     * Vesicular: Soft sounds heard over the peripheral lung fields.     * Adventitious Sounds:         * Wheezes: Musical/high-pitched whistling (bronchospasm).         * Rhonchi: Low-pitched rumbling (secretions in large airways).         * Crackles (Rales): Popping sounds (fluid in alveoli).         * Stridor: Piercing high-pitched sound on inspiration.         * Stertor: Snoring sound.

• Heart Sounds Landmarks:     * Aortic: 2nd Intercostal space (ICS), right sternal border.     * Pulmonic: 2nd ICS, left sternal border.     * Erb's Point: 3rd ICS, left sternal border.     * Tricuspid: 4th ICS, left sternal border.     * Mitral: 5th ICS, midclavicular line.     * Extra Sounds: $S_3$ (rapid filling), $S_4$ (atrial contraction), Murmurs (turbulent flow), and Pericardial Friction Rub.

Abdominal, Urinary, and Musculoskeletal Systems

• Abdominal Assessment Sequence: Inspect, Auscultate, Percuss, Palpate (Look, Listen, Feel). Auscultate for Bruits over major arteries (Aorta, Renal).
• Urinary terms: Anuria (no urine), Oliguria (reduced urine), Polyuria (excessive urine).
• Musculoskeletal: Assess symmetry, gait, and spinal curvature (Scoliosis, Kyphosis, Lordosis). Conduct the Romberg test for balance.

Cranial Nerves and Reflexes

• Cranial Nerves (Acronym: Oh Oh Oh To Touch And Feel Very Good Velvet Ah):     * I (Olfactory): Sensory - Smell (Sniff test).     * II (Optic): Sensory - Vision (Snellen chart).     * III (Oculomotor): Motor - EOM and PERRLA.     * IV (Trochlear): Motor - Eye movement.     * V (Trigeminal): Both - Jaw strength and facial touch.     * VI (Abducens): Motor - Eye movement.     * VII (Facial): Both - Facial expressions and taste (anterior tongue).     * VIII (Vestibulocochlear): Sensory - Hearing/Balance (Weber/Rinne).     * IX (Glossopharyngeal): Both - Gag reflex and taste (posterior tongue).     * X (Vagus): Both - Gag/Swallow.     * XI (Accessory): Motor - Shoulder shrug.     * XII (Hypoglossal): Motor - Tongue movement.

• Reflex Grading Scale:     * $0$: No response.     * $1+$: Low normal.     * $2+$: Normal.     * $3+$: Brisker than normal.     * $4+$: Hyperactive/Brisk.