Chapter 22 Physical Assessment
What are the 6 techniques used for physical assessment? - answer Interview
Inspection (observation)
Percussion
Auscultation
Palpation
Olfaction
objective is - answer What you observe
subjective is - answer what the patient tells you
skin turgor is - answer elasticity of skin
What is the most common type of percussion? - answer consists of striking the middle
finger of one hand with the middle or index finger of the other hand
Percussion sounds vary in - answer intensity, pitch, and duration.
percussion force is - answer generated with a quick snap of the wrist; don't move the
forearm
percussion helps in determining - answer Size of organs
Location of organs
Density of organs
Presence of air or fluids in tissue or in a body cavity
percussion is - answer Light, quick tapping on the body surface to produce sounds
inspection/observation - answer visually examining
What are sounds heard with auscultation - answer Heart sounds
Breath sounds
Bowel sounds
Murmurs: abnormal heart valve sounds
Bruits: rushing of blood through a vessel
auscultation is - answer Listening to presence or absence of body sounds using a
stethoscope
when auscultating use - answer the diaphragm for normal S1-S2 and to count heart rate
the bell for some abnormal heart sounds
olfaction - answer smelling with your nose
olfaction can be smelled for - answer Breath odor for sweetness, acetone, or alcohol
Wound odors
, Chapter 22 Physical Assessment
Odors from discharges such as vaginal infections
Palpation - answer point of maximum impulse
strength of hand grips and foot flexion
Head to toe assessment includes - answer Neurological
Cardiovascular
Respiratory
Integumentary
Gastrointestinal
Genitourinary
Muscular
Skeletal
Briefly, the immune
assessment findings - answer Please note that a lot of assessment findings can be
classified in more than one body system!!
Neurological exam/check - answer Vital signs
Level of consciousness (AAOx 4)
Orientation to four spheres (person, place, time and situation)
Pupil size, equality, and reaction to light
Facial symmetry
Speech clarity and appropriateness
Response to simple commands
Movement, strength, and bilateral equality of four extremities
Dysphasic - answer refers to a patient who has difficulty coordinating and/or organizing
words spoken
Dysphagia - answer means that the patient has difficulty swallowing
Aphasic - answer unable to verbalize
neruo check - answer Performed at regular intervals on patients who have had a head
injury or brain surgery
Pupil size is measured
Patient is asked to track the nurse's finger or an object as it is moved to six different
positions
PERRLA - answer pupils equal round reactive to light and accomadating
Consensual reflex: - answer stimulation of one pupil with light, causes both pupils to
constrict rapidly, simultaneously and equally
What are the 6 techniques used for physical assessment? - answer Interview
Inspection (observation)
Percussion
Auscultation
Palpation
Olfaction
objective is - answer What you observe
subjective is - answer what the patient tells you
skin turgor is - answer elasticity of skin
What is the most common type of percussion? - answer consists of striking the middle
finger of one hand with the middle or index finger of the other hand
Percussion sounds vary in - answer intensity, pitch, and duration.
percussion force is - answer generated with a quick snap of the wrist; don't move the
forearm
percussion helps in determining - answer Size of organs
Location of organs
Density of organs
Presence of air or fluids in tissue or in a body cavity
percussion is - answer Light, quick tapping on the body surface to produce sounds
inspection/observation - answer visually examining
What are sounds heard with auscultation - answer Heart sounds
Breath sounds
Bowel sounds
Murmurs: abnormal heart valve sounds
Bruits: rushing of blood through a vessel
auscultation is - answer Listening to presence or absence of body sounds using a
stethoscope
when auscultating use - answer the diaphragm for normal S1-S2 and to count heart rate
the bell for some abnormal heart sounds
olfaction - answer smelling with your nose
olfaction can be smelled for - answer Breath odor for sweetness, acetone, or alcohol
Wound odors
, Chapter 22 Physical Assessment
Odors from discharges such as vaginal infections
Palpation - answer point of maximum impulse
strength of hand grips and foot flexion
Head to toe assessment includes - answer Neurological
Cardiovascular
Respiratory
Integumentary
Gastrointestinal
Genitourinary
Muscular
Skeletal
Briefly, the immune
assessment findings - answer Please note that a lot of assessment findings can be
classified in more than one body system!!
Neurological exam/check - answer Vital signs
Level of consciousness (AAOx 4)
Orientation to four spheres (person, place, time and situation)
Pupil size, equality, and reaction to light
Facial symmetry
Speech clarity and appropriateness
Response to simple commands
Movement, strength, and bilateral equality of four extremities
Dysphasic - answer refers to a patient who has difficulty coordinating and/or organizing
words spoken
Dysphagia - answer means that the patient has difficulty swallowing
Aphasic - answer unable to verbalize
neruo check - answer Performed at regular intervals on patients who have had a head
injury or brain surgery
Pupil size is measured
Patient is asked to track the nurse's finger or an object as it is moved to six different
positions
PERRLA - answer pupils equal round reactive to light and accomadating
Consensual reflex: - answer stimulation of one pupil with light, causes both pupils to
constrict rapidly, simultaneously and equally
