Body assessment 1
what part of the stethoscope do you use to hear heart valve sounds?
The bell of the stethoscope
what is the normal capillary refill time?
less that 3 seconds
what are the 5 P's nurses assess for in a neurovascular assessment
pain, pulse, pallor, parasthesia, and paralysis
PERRLA?
pupils equal, round, and reactive to light
what is percussion?
quick tapping on the body to produce sound
should pupil size be measured under dim, normal, or bright light conditions?
normal light
what are examples of abnormal lung sounds?
wheeze, gurgle, crackles, stertor, and stridor
what is the first step in a physical exam technique to observe a patient's physiological condition?
Inspection
(rashes, skin tone, scars etc)
Patients should be assessed from ____ to ____
head to toe
what is edema?
fluid in the tissues (aka swelling)
muscle spasms or rigidity
pain, swelling, or a growth
any restriction in moving a body part
skin temp and edema
where is the best place to auscultate for both the heart rate and rhythm?
apex. 5th intercostal space, left midclavicular line
what is something the nurse can do to observe the patient's muscle strength?
have patient push against your hands with the sole of one foot and then with the other.
have patient grasp your fingers. (checks for the degree and equality strength of both hands)
Aslea Elliot, Maykayla Cannady-Smith, and Arnaijah Bryant
PERIOD!!!
what is olfaction?
sense of smell
How do you check for dehydration using turgor assessment?
gently pinching up a bit of skin on the arm or over the sternum
how do you compare peripheral pulses?
bilaterally
2 parts!
what is the nurse looking for while shining the light in a patient's eye?
what is the nurse looking for while asking the patient to follow their finger with their eyes?
1. pupil constriction
2. nystagmus (jerky movements)
what is the order of observation in a shift head to toe assessment?
Initial observation(skin color, appearance), Head, Vital signs, Pain, Chest, or heart and lungs, abdomen, and extremities
what is ascites?
abnormal accumulation of serous fluid within the peritoneal cavity
where is the apex and base of the lungs located?
what part of the stethoscope is used to listen to lung sounds?
apex= above clavicle
base= on the back
diaphragm
a very pertinent part of the physical exam on a patient with back pain is
1. inspection of extremities
2. auscultation of bowel sounds
3. percussion of the flank areas of the back
4. auscultate the lungs
3. percussion of the flank areas of the back
what are 4 things the nurse can ask to check a patient's mental orientation status?
where are you right now?
who is the current president?
what month is it?
what is your name?
what is RNS HOPE
acronym to remember areas to assess concerning basic needs
Rest and activity
Nutrition, fluids and electrolytes
Safety and security
Oxygenation and circulation needs
Psychological and learning
Elimination
what are vesicular sounds?
the soft, rustling sounds heard on the periphery of the lungs