Term
| What are the purposes of the Nursing Physical Assessment? |
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Definition
It provides baseline data for the nursing diagnosis and plan of care
It supplements, confirms, or refutes information from the nursing history
It helps to make clinical judgements on the patient's health status
It is used to evaluate the health and progress of the patient |
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Term
| When performing a head to toe physical assessment, what four techniques are used with each patient and on each body system of the patient? |
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Definition
| Inspection, Palpation, Percussion and Auscultation |
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Term
| When using Palpation, what you assess on a patient? |
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Definition
Temperature
Edema
Texture
Vibration
Motility of organs
Distention
Pulsation
Pain upon pressure
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Term
| Describe the normal breath sounds a nurse should hear when auscultating a patient's lungs and the locations where each sound is best heard |
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Definition
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Vesicular sounds are soft, blowing or rustling sounds normally heard throughout most of the lung fields. Vesicular sounds are normally heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration
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Bronchial sounds are present over the large airways in the anterior chest near the 2nd and 3rd intercostal spaces, Bronchial sounds are high in pitch, louder and more tubular and hollow-sounding than vesicular sounds, but not as harsh as tracheal breath sounds. Expiratory sounds last longer than inspiratory sounds or duration is the same. Intensity of inspiration and expiration is the same. There is a short gap between inspiration and expiration.
Bronchovesicular sounds are heard in the posterior chest between the scapulae and in the center part of the anterior chest. Bronchovesicular sounds are softer than bronchial sounds, but have a tubular quality. Bronchovesicular sounds are about equal during inspiration and expiration; differences in pitch and intensity are often more easily detected during expiration.
Tracheal breath sounds are heard over the trachea. These sounds are harsh and sound like air is being blown through a pipe.
In a normal air-filled lung, vesicular sounds are heard over most of the lung fields, bronchovesicular sounds are heard between the 1st and 2nd interspaces on the anterior chest, bronchial sounds are heard over the body of the sternum, and tracheal sounds are heard over the trachea.
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Term
| Describe abnormal breath sounds that a nurse might auscultate |
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Definition
Weezing This is the sound of wheezing when auscultating breath or lung sounds. It can be heard when there is an airway obstruction such as when you listen to a patient with mild to moderate asthma during an exacerbation. Wheeze is mainly expiratory and occurs during both phases..
Fine Crackles (aka Rales) are high pitched sounds mostly heard in the lower lung bases. This can be abnormal findings on physical exam suggestive of things like congestive heart failure, pneumonia or atelectasis.
Coarse Crackles are low pitched lungs sounds heard in pathologies such as chronic bronchitis, bronchiectasis, pneumonia, and severe pulmonary edema. Compared to fine crackles, they are often louder, longer in duration and lower in pitch.
Pleural rub is nonmusical, short,. biphasic (inspiro-expiratory) explosive sound (grating, rubbing, creaky, or leathery). It occurs due to inflamed pleural surface rubbing each other during breathing.
Stridor is loud, high-pitched, mainly inspiratory, musical sound produced by upper respiratory tract obstruction. It is different from wheezing: It is louder over the neck than chest wall. In expiration, it is biphasic. Stridor is caused by the turbulent flow passing through a narrowed segment of the upper respiratory tract. |
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Term
| When assessing bowel sounds, in which order does the nurse perform the techniques? Give the rationale |
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Definition
| Inspection, Auscultation, then Percussion and Palpation. A nurse should listen to assess sounds before stimulating bowel activity with touch and thus falsely increasing bowel sounds. |
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Term
| During report you learn that your patient has a bruit on their L carotid artery. During auscultation of this artery, you should hear what? |
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Definition
| A bruit creates a blowing or swishing sound. It sounds like a clogged drain and is caused by turbulence due to a narrowing of the lumen or increased cardiac output. This is an abnormal finding. |
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Term
| Jugular vein distention could be a sign of? |
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Definition
| Right-sided heart failure. The atrium is not allowing blood to flow freely to the heart. |
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Term
| When assessing blood supply to the BLE's, what pulses do you palpate? |
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Definition
| Posterior Tibial and Dorsal Pedal pulses |
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Term
| What Mnemonic is used for symptom assessment? |
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Definition
OLDCART
O-Onset (acute vs. gradual)
L-Location
D-Duration
C-Characteristics
A-Aggravating Factors
A-Associated Manifestations
R-Relieving Factors
T-Treatments (and response)
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