Fundamentals of Nursing: Major Body Assessments Chapter 26 Flashcards

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Comprehensive health assessment

- Broad health assessment that includes a complete health history and physical assessment


When is a comprehensive health assessment usually conducted?

- When a patient first enters a health care setting. Information provides a baseline for comparing later assessments.


Ongoing assessment

- AKA follow-up assessment and conducted at regular intervals e.g. beginning of each shift


Ongoing assessments concentrate on:

- Identified health problems to monitor positive or negative changes - And evaluate the effectiveness of interventions.


Focused health assessment

- Conducted to assess a specific problem e.g. Woman c/o abd pain. Nurse asks questions about urinary problems, bowel problems, allergies, and menstrual history


Health History

A collection of subjective information (information gathered from the patient) that provides information about the patient's health status.


Physical Assessment

- Collection of objective data that provides information about changes in the patient's body systems


Activities of daily living (ADLs)

- Self-care activities that include: Eating, bathing, dressing, toileting, personal hygiene...


Instrumental activities of daily living (IADLs)

- Activities needs for independent living such as: Housekeeping, mean preparation, management of finances, transportation...


Standing position is used to assess:

- Posture, balance, and gait


Sitting position is used to assess:

- Vital signs, head/neck, anterior and posterior thorax, lungs, heart, breasts, and upper extremities. - Allows visualization of the upper body and facilitates full lung expansion


Supine position is used to assess:

- Vital signs, head/neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses - Facilitates abdominal muscle relaxation


Dorsal recumbent position is used to assesses:

- Head/neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses - DO NOT used for abdominal assessment as it contracts abdominal muscles


Sim's position is used to assess:

- Rectum or vagina


Prone position is used to assess:

- Hip joint and posterior thorax


Lithotomy position is used to assess:

- Female genitalia and rectum


Knee-chest position is used to assess:

- Anus and rectum


What are the four primary assessment techniques?

- Inspection - Palpation - Percussion - Auscultation


Inspection is the process of:

- Performing deliberate, purposeful observations in a systematic manner. Also use hearing and smell to gather data. - Inspect body for size, color, shape, position, movement, and symmetry


Palpation is the process of:

- Touching using the hands and fingers to assess skin temperature, turgor, texture, and moisture. - Also used to define shape or structure within the body.


Percussion is the act of:

- Producing sound by striking one object against another. - Characteristics of sounds are used to assess the location, shape, size, and density of tissues.


Auscultation is the act of:

- Listening with a stethoscope to sounds produced within the body.


Characteristics of sound assessed by auscultation include:

- Pitch (ranging from high to low) - Loudness (ranging from soft to loud) - Quality (gurgling or swishing) - Duration (short, medium, long)


Sequence of techniques used during an examination of the abdomen are:

- Inspection - Auscultation - Percussion - Palpation (Percussion and palpation are done last because they stimulate bowel sounds)


Right Upper Quadrant (RUQ) of abdomen includes:

- Pylorous - Duodenum - Liver - Right kidney and adrenal gland - Hepatic flexure of colon - Head of pancreas


Left Upper Quadrant (LUQ) of abdomen includes:

- Stomach - Spleen - Left kidney and adrenal gland - Splenic flexure of colon - Body of pancreas


Right Lower Quadrant (RLQ) of abdomen includes:

- Cecum - Appendix - Right over and fallopian tube (female) - Right ureter and lower kidney pole - Right spermatic cord (male)


Left Lower Quadrant (LLQ) of abdomen includes:

- Sigmoid colon - Left over and fallopian tube (female) - Left ureter and lower kidney pole - Left spermatic cord (male)


Midline of the abdomen includes:

- Urinary bladder - Urethra (female)


Inspection of the abdomen includes:

- Skin color and characteristics - Umbilicus - Contour - Symmetry - Peristalsis - Pulsations - Visible masses and scars


Auscultation of the abdomen includes:

- Assess bowel sounds and vascular sounds - Listen for a full two minutes before documenting - Note frequency and character of bowel sounds


What sequence should you use to auscultate abdominal sounds?

Start in the RLQ, then to RUQ, then LUQ, and finish in the LLQ.


Palpation of the abdomen includes:

- Using pads of fingers with light, dipping motion of approximately 1 cm - Palpate each quadrant in a systematic manner. - Note muscular resistance, tenderness, enlargement of organs, or masses


Percussion of abdomen

- percuss lightly on all 4 quadrants - tympany should dominate b/c air rises to GI surface when pt is supine *dullness occurs over a distended bladder, adipose tissue, fluid, or a mass *hyperresonance is present with gaseous distention


Common abdominal variations in newborns include:

- Umbilical cord that dries and falls off within the first few weeks of life


Common abdominal variations in children include:

- "Pot-Belly" (under 5 years of age) - Visible peristaltic waves


Common abdominal variations in older adults include:

- Decreased bowel sounds - Decreased abdominal tone - Fat accumulation on the abdomen and hips


The thorax comprises the:

- Lungs - Rib cage - Cartilage - Intercostal muscles


Physical examination of the thorax lungs provides data about the:

- Bony structures of the thorax - Respiratory effect - Chest expansion - Breath sounds


Inspect the thorax for:

- Color (should be same color as the face) - Thorax should have a downward, equal slope at the rib cage - Shape or contour (normal or barrel chest) Transverse diameter should be greater than the anteroposterior diameter - Breathing patterns - Muscle development


Palpation of the thorax is used to detect:

- Areas of sensitivity - Chest expansion during respiration - Vibration (fremitus)


Chest expansion is determined by:

- Placing hands over posterior chest wall with fingers at level of T9 or T10. - When pt takes a deep breath your thumbs should move apart as the thorax expands symmetrically


Normal breath sounds: Bronchial (Tubular)

- Heard over the larynx or trachea - High pitches, harsh "blowing" sounds. - Expiration sound is longer, lower, and higher-pitched than inspiration sound


Normal breath sounds: Bronchovesicular

- Heard over the first and second intercostal spaces next the sternum - Medium pitched blowing sounds - Inspiration and expiration sounds have similar pitch and duration


Normal Breath Sounds: Vesicular

- Heard over most of the lung fields - Soft, low pitched, whispering sounds - Inspiration is longer, louder, and higher-pitched than expiration


Adventitious breath sounds: Wheeze

- Continuous high pitched, musical or squeaking sounds. - Auscultated during inspiration and expiration - Air passing through narrowed airways


Adventitious breath sounds: Rhonchi

- Continuous coarse, snoring quality, low pitched sounds - Auscultated during inspiration and expiration - Coughing may clear sound somewhat - Air passing through or around secretions


Adventitious breath sounds: Crackles

- Discontinuous low to high pitched bubbling, crackling, popping sounds - Auscultated during inspiration and expiration - Opening of deflated small airways and alveoli -air passing through fluid in the airways


Adventitious breath sounds: Stridor

- Harsh, loud, high-pitched - Auscultated on inspiration - Narrowing of upper airway (larynx or trachea)- presence of foreign body in airway


Adventitious breath sounds: Friction Rub

- Rubbing or grating - Loudest over lower lateral anterior surface - Auscultated during inspiration and expiration - Inflamed pleura rubbing against chest wall


Normal Age-Related Thorax & Lung Variation in Infants/Children include:

- Louder breath sounds on auscultation - More rapid respiratory rate - Use of abdominal muscles during respiration


Normal Age-Related Thorax & Lung Variation in Older Adults include:

- Increased anteroposterior chest diameter - Increased dorsal spinal curve (kyphosis) - Decreased thoracic expansion - Use of accessory muscle to exhale


Inspection of the cardiovascular system includes:

- Observing the neck and the precordium (portion of body over the heart and lower thorax) for visible pulsations - Pulsations usually are absent except for the apical impulse, located at about the fourth or fifth intercostal space at the left midclavicular line.


jugular vein distention (JVD)

A visual bulging of the jugular veins in the neck that can be caused by fluid overload, pressure in the chest, cardiac tamponade, or tension pneumothorax.


APE To Man stands for:

card image

- Aortic - Pulmonic - Erb's point - Tricuspid - Mitral


Auscultate carotid arteries using the ______ of the stethoscope.



When auscultating carotid arteries an abnormal "swooshing or blowing" sound heard over a blood vessel caused by blood swirling in the vessel rather than flowing smoothly is called a _________.



First heart sound

S1, "lub" of "lub-dub" occurs when:, - The mitral and tricuspid valves close and correspond to the onset of ventricular contraction - Low-pitched, dull. S1 is louder at the tricuspid and apical areas.


Second heart sound

S2, "dub" of "lub-dub" occurs when:, - At the termination of systole and corresponds to the onset of ventricular diastole. - The "dub" represents the aortic and pulmonic valves closing - Higher-pitched and shorter than S1. - S2 is louder at the aortic and pulmonic areas


Cardiovascular and Peripheral Vascular Variation in Newborns/Children include:

- Visible cardiac pulsation if the chest wall is thin - Sinus dysrhythmia (the rate increases with inspiration and decreases with expiration) - Presence of S3 (in about one third of all children) - More rapid heart rate (until about 8 years of age)


Common Cardiovascular and Peripheral Vascular Variations in older adults include:

- Difficult-to-palpate apical pulse - Difficult-to-palpate distal arteries - More prominent and tortuous blood vessels varicosities common - Increased systolic and diastolic blood pressure - Dilated proximal arteries - Widening pulse pressure


Peripheral Vascular Assessment: Inspection

- Inspect skin of extremities for color, continuity, lesions, venous patterns, edema


Peripheral Vascular Assessment: Palpation

- Use pads of index and middle fingers to palpate peripheral pulses for amplitude and symmetry - Palpate carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses. Should be strong and equal bilaterally


Normal capillary refill time is:

less than (<) 3 seconds


Auscultation of lungs includes:

- Listening for breath sounds (note duration, pitch, intensity) - adventitious sounds (abnormal breath sounds) - Use same sequential pattern to listen that was used to palpate (a ladder pattern)