Nursing 110- Exam 2 Study Guide
Physical Assessment
-Purpose of Physical Assessment
•Gather a health history. Primary purpose of Physical Assessment
•Develop nursing diagnosis and care plan.
•Manage client problems.
•Evaluate nursing care.
-Sitting Positions TABLE 31-2 PG 536
-Subjective Data- Symptoms/ what the patient says/ health history
-Objective Data- Signs/ What you assess/ physical assessment and diagnostic test
-Dont ask leading question when interviewing- use open ended questions
-ask patient to clarify what you’ve heard and then summarize what they said
-when investigating pain asses for- location, quality, quantity, leading factors, and have them
use one finger to point to affected location. (some due to nerve endings)
- assess previous level of functioning
-Techniques for Physical Exam
-Inspection> Palpation (TABLE 31-5/ Start with light palpation and end with deep)>
Percussion> Auscultation> Olfaction TABLE 31-4
-Techniques for Physical Exam On Abdomen
-Inspection (distended, concave, how it looks)> Auscultation (Diaphragm Steth. Listen to
Bowel sounds, all 4 quadrants) > Palpation
-Palpation- Light:½ inch- Deep: 2 in.
- Percussion- tapping body parts with finger (denser the tissue quieter the sound)
Resonant- low pitched, hollow, heard of normal lung tissue
Flat- over bone
Dull/ Thud Like- dense area (heart liver) or fluid or solid tissue replace air in lungs
-Stethoscope- Bell- low pitched sounds (bruits, press lightly) Diaphragm- high pitched
Sounds (heart, bowel, lung sounds, and bruits {bruits- created by turbulence in major artery due to to
blockages or increased vasculature such as enlarged thyroid press firmly}) BOX 31-2 PG 541
-2 Types of Latex allergies: 1- The body develops antibodies known as immunoglobulin E which
can lead to an anaphylactic response. 2- allergic contact dermatitis type 4 response, which
, causes a delayed reaction that appears 12 -48 hours after exposure. Both require prior
exposure to the substance. TABLE 31-1 PG 535
- Prep for Exam: Equipment> Psychological Prep for client> Assessment of age groups
-Tips: Compare both sides for symmetry/ seriously ill clients assess body system most at risk
first, allow rest period if client fatigues easily, document findings in approved documentation
records
- General Survey (1st encounter inspection)- 1) appearance: groomed? In need of basic care?
2) vital signs: baseline, last time ate, drank, smoked, exercise, medications 3) height and weight
- Summary of what you can assess in general survey- •Signs of distress, body type, posture,
gait, body movements, hygiene, grooming, dress, body odor, mood, affect, and speech
Skin, Head, Eyes, Ears, and Neck
Skin Assessment: Inspection and Palpation
Integumentary system- skin, hair, scalp, and anils
TABLE 31-6
-Temperature is best assessed using the dorsal (back) of the hand.
-Assessing skin note: color, moisture, temp. Texture, turgor (elasticity of skin), Vascularity
(pressure areas), Edema (build up of fluid in the tissues caused by trauma or impairments of
venous return)
Petechiae are pinpoint size, red/ purple spots on the skin caused by small hemorrhages
Table 31-8 Skin Colors
Pallor (Pale/ decrease in color)- decreased blood flow from shock or anemia
Cyanosis- bluish color in nails, skin, mouth/ indicated heart & lung disease, cold
environment, decreased oxygen in blood
Erythema- Red Discoloration caused by increased blood flow due to fever, trauma,
blushing, alcohol intake, sunburn, and inflammation.
-shiny scaly brown skin and red taught shiny skin indicates vascular insufficiency
TABLE 31-9 PG 547
Jaundice- yellow-orange discoloration- best place to inspect is patients sclera. Caused
from increased deposits of bilirubin in tissues (Liver Disease)
-types of Edema: dependent, pitting (when pressure from the examiners’ fingers leaves an
indentation) FIGURE 31-6 PG 548 , due to injury, obstruction
Physical Assessment
-Purpose of Physical Assessment
•Gather a health history. Primary purpose of Physical Assessment
•Develop nursing diagnosis and care plan.
•Manage client problems.
•Evaluate nursing care.
-Sitting Positions TABLE 31-2 PG 536
-Subjective Data- Symptoms/ what the patient says/ health history
-Objective Data- Signs/ What you assess/ physical assessment and diagnostic test
-Dont ask leading question when interviewing- use open ended questions
-ask patient to clarify what you’ve heard and then summarize what they said
-when investigating pain asses for- location, quality, quantity, leading factors, and have them
use one finger to point to affected location. (some due to nerve endings)
- assess previous level of functioning
-Techniques for Physical Exam
-Inspection> Palpation (TABLE 31-5/ Start with light palpation and end with deep)>
Percussion> Auscultation> Olfaction TABLE 31-4
-Techniques for Physical Exam On Abdomen
-Inspection (distended, concave, how it looks)> Auscultation (Diaphragm Steth. Listen to
Bowel sounds, all 4 quadrants) > Palpation
-Palpation- Light:½ inch- Deep: 2 in.
- Percussion- tapping body parts with finger (denser the tissue quieter the sound)
Resonant- low pitched, hollow, heard of normal lung tissue
Flat- over bone
Dull/ Thud Like- dense area (heart liver) or fluid or solid tissue replace air in lungs
-Stethoscope- Bell- low pitched sounds (bruits, press lightly) Diaphragm- high pitched
Sounds (heart, bowel, lung sounds, and bruits {bruits- created by turbulence in major artery due to to
blockages or increased vasculature such as enlarged thyroid press firmly}) BOX 31-2 PG 541
-2 Types of Latex allergies: 1- The body develops antibodies known as immunoglobulin E which
can lead to an anaphylactic response. 2- allergic contact dermatitis type 4 response, which
, causes a delayed reaction that appears 12 -48 hours after exposure. Both require prior
exposure to the substance. TABLE 31-1 PG 535
- Prep for Exam: Equipment> Psychological Prep for client> Assessment of age groups
-Tips: Compare both sides for symmetry/ seriously ill clients assess body system most at risk
first, allow rest period if client fatigues easily, document findings in approved documentation
records
- General Survey (1st encounter inspection)- 1) appearance: groomed? In need of basic care?
2) vital signs: baseline, last time ate, drank, smoked, exercise, medications 3) height and weight
- Summary of what you can assess in general survey- •Signs of distress, body type, posture,
gait, body movements, hygiene, grooming, dress, body odor, mood, affect, and speech
Skin, Head, Eyes, Ears, and Neck
Skin Assessment: Inspection and Palpation
Integumentary system- skin, hair, scalp, and anils
TABLE 31-6
-Temperature is best assessed using the dorsal (back) of the hand.
-Assessing skin note: color, moisture, temp. Texture, turgor (elasticity of skin), Vascularity
(pressure areas), Edema (build up of fluid in the tissues caused by trauma or impairments of
venous return)
Petechiae are pinpoint size, red/ purple spots on the skin caused by small hemorrhages
Table 31-8 Skin Colors
Pallor (Pale/ decrease in color)- decreased blood flow from shock or anemia
Cyanosis- bluish color in nails, skin, mouth/ indicated heart & lung disease, cold
environment, decreased oxygen in blood
Erythema- Red Discoloration caused by increased blood flow due to fever, trauma,
blushing, alcohol intake, sunburn, and inflammation.
-shiny scaly brown skin and red taught shiny skin indicates vascular insufficiency
TABLE 31-9 PG 547
Jaundice- yellow-orange discoloration- best place to inspect is patients sclera. Caused
from increased deposits of bilirubin in tissues (Liver Disease)
-types of Edema: dependent, pitting (when pressure from the examiners’ fingers leaves an
indentation) FIGURE 31-6 PG 548 , due to injury, obstruction
