N174 PHYSICAL ASSESSMENT + LAB COMPONENT
NURSING 2024/2025 A+ GRADE REVISION
MATERIAL.
1 . Identify and list the 5 steps of the Nursing Process: Assessment:
gathering data, subjective and objective, first interview. Diagnosis:
identify problem, nursing diagnosis.
Planning/Outcomes: create goals, objective. goals, general goals.
Implementation: carry out the plan.
Evaluation: gather data to see if goals are achieved, make sure the
implementation os pt care is working, if not repeat steps.
2. Define health assessment and list the three parts: Definition:
systematic method of collecting data, organized in a specific order
to follow each time so you don't miss steps: employs objective and
subjective data, organize data, analyze data, interpret findings,
utilize critical thinking to evaluate the data.
Three Parts:
- Interview: health history
- Physical Assessment: observed and measured
- Documentation: if not documented you did no do it according to
law/everywhere. 3. Understand the components of health history and
documentation: - Identifying data/ biographic data
- Chief Complaint (CC):complaint, symptom, length of duration
- History of Present Illness (HA): OLDCART & ICE, & PQRST
- Past Medical History (PMHx)
- Social History (SHx)
- Family History CA, CVA, DM, HTN, CAD
- Psychosocial History
,- Review of Body Systems: General, Derm/Hair/Nails, HEENT,
Respiratory, Cardiovascular/ Peripheral Vascular, G',
Reproductive/OB, Musculoskeletal, Neurological, Psychiatric
Onset, Location, Duration, Characteristics, Aggravation, Relieving,
Treatment... Impact of ADLs, Coping strategies, Emotional
response... Provokes, Quality/Quantity, Radiation/ Region, Severity,
Timing, Understanding
4. Describe the difference between subjective data and objective
data: Subjective: CC, HPI, ROS,PMHx, FHx, Sl--lx
Objective: hands-on exam of pt, survey and exam body systems,
observe and measure pt, data is seen/felt/ heard (inspection,
palpation, percussion, auscultation) 5. Familiarize oneself with the
basic techniques when performing the physical exam: -Inspection:
color, size, shape, symmetry, contour, movement, drainage
-Palpation: touch, too-painful, too-little pressure, size, shape, mobility,
location,
position
- Percussion: audible sound, determine size, shape of vibration,
temperature, texture, organs filled with excess air or fluids, moisture,
edema
- Auscultation: listen to sounds produced by the body, the body/
intensity/ pitch/ duration/ quality
Documentation: flow sheets, narrative sheets/ nursing notes, electronic
health records
,6. Best areas to assess facial symmetry: -nasolabial fold (mouth
area)
- palpebral fissure (eyes area from lid to bottom lashes
- lateral canthus to pinna are equal
7. Structures, Triangles, Vessels of Neck: Structures: hyoid bone,
thyroid cartilage, thyroid gland, cricoid cartilage, isthmus thyroid,
trachea, clavicle, manubrium, sternocleiodmastoid msucle
Triangles: anterior triangle- clavicle, trapezius muscle, omohyoid muscle;
posterior triangle-sternocleidomastoid muscle, anterior triangle
Vessels: Temporal Artery&vein, external carotid artery, internal carotid
artery, common carotid artery, sternocleiodomastoid muscle, internal
jugular vein, external jugular vein, clavicle
8. Suggested Palpation of the Lymphnodes: Pre auricular, post
auricular, occipital, retrophayngeal (tonsillar), submaxillary
(submandibular), submental, superficial cervical chain, deep cervical
chain, suprclavicular
9. Normal and abnormal findings for Head, neck, face:
10. Normal and abnormal findings for Eyes:
1 1 . Normal and abnormal findings for Ears: Normal: Ears are
symmetric and intact, color is pink, no redness, nodules, swelling or
lesions, external auditory meatus is patent with no drainage, No pain
or tenderness on palpation of the external ear and mastoid process
Abnormal:
12. Normal and abnormal findings for Nose:
13. Normal and abnormal findings for Mouth and Throat: Normal:
Mucosa of the oral cavity is pink, intact, moist, no visible lesions,
3/32
, gums are pink, intact, moist, no visible lesions, no sensitivity of
teeth, no malocclusion;
No palpable lymphadenopathy, Trachea midline, no palpable
deviation Abnormal: 14. Describe variations in techniques and
findings: - Normocephalic, head midline, skull and facial structures
intact and symmetric, skin intact, facial movements symmetric and
smooth, no tenderness with palpation to scalp and neck, palpable
temporal arteries, TMJ full ROM with no palpable tenderness or
crepitus, neck full ROM, trachea midline, no facial or neck
lymphadenopathy
- Hair - medium brown, curly, fine texture, with receding frontal hairline.
Skull and facial features symmetric. Smiles, frowns, shows teeth, puffs
cheeks, wrinkles forehead and closes eyelids tightly (CN VII intact). Full
ROM of TMJ, no palpable crepitus. No sinus tenderness with
palpation/percussion. Two bilateral submandibular 1 cm lymph nodes,
firm, mobile, non-tender. No other noted lymphadenopathy. Trachea
midline. Full ROM of neck.
15. Discuss related Healthy People 2020 objectives: - Reduce sports
and recreational injuries.
- Reduce deaths caused by motor vehicle crashes.
- Increase the use of safety belts.
- Increase the use of helmets by cyclists.
- Reduce deaths by falls.
16. Pertinent History for Respiratory tract: - Any chronic
conditions
Asthma, COPD, CHF, DM
Exposure to new medication
NURSING 2024/2025 A+ GRADE REVISION
MATERIAL.
1 . Identify and list the 5 steps of the Nursing Process: Assessment:
gathering data, subjective and objective, first interview. Diagnosis:
identify problem, nursing diagnosis.
Planning/Outcomes: create goals, objective. goals, general goals.
Implementation: carry out the plan.
Evaluation: gather data to see if goals are achieved, make sure the
implementation os pt care is working, if not repeat steps.
2. Define health assessment and list the three parts: Definition:
systematic method of collecting data, organized in a specific order
to follow each time so you don't miss steps: employs objective and
subjective data, organize data, analyze data, interpret findings,
utilize critical thinking to evaluate the data.
Three Parts:
- Interview: health history
- Physical Assessment: observed and measured
- Documentation: if not documented you did no do it according to
law/everywhere. 3. Understand the components of health history and
documentation: - Identifying data/ biographic data
- Chief Complaint (CC):complaint, symptom, length of duration
- History of Present Illness (HA): OLDCART & ICE, & PQRST
- Past Medical History (PMHx)
- Social History (SHx)
- Family History CA, CVA, DM, HTN, CAD
- Psychosocial History
,- Review of Body Systems: General, Derm/Hair/Nails, HEENT,
Respiratory, Cardiovascular/ Peripheral Vascular, G',
Reproductive/OB, Musculoskeletal, Neurological, Psychiatric
Onset, Location, Duration, Characteristics, Aggravation, Relieving,
Treatment... Impact of ADLs, Coping strategies, Emotional
response... Provokes, Quality/Quantity, Radiation/ Region, Severity,
Timing, Understanding
4. Describe the difference between subjective data and objective
data: Subjective: CC, HPI, ROS,PMHx, FHx, Sl--lx
Objective: hands-on exam of pt, survey and exam body systems,
observe and measure pt, data is seen/felt/ heard (inspection,
palpation, percussion, auscultation) 5. Familiarize oneself with the
basic techniques when performing the physical exam: -Inspection:
color, size, shape, symmetry, contour, movement, drainage
-Palpation: touch, too-painful, too-little pressure, size, shape, mobility,
location,
position
- Percussion: audible sound, determine size, shape of vibration,
temperature, texture, organs filled with excess air or fluids, moisture,
edema
- Auscultation: listen to sounds produced by the body, the body/
intensity/ pitch/ duration/ quality
Documentation: flow sheets, narrative sheets/ nursing notes, electronic
health records
,6. Best areas to assess facial symmetry: -nasolabial fold (mouth
area)
- palpebral fissure (eyes area from lid to bottom lashes
- lateral canthus to pinna are equal
7. Structures, Triangles, Vessels of Neck: Structures: hyoid bone,
thyroid cartilage, thyroid gland, cricoid cartilage, isthmus thyroid,
trachea, clavicle, manubrium, sternocleiodmastoid msucle
Triangles: anterior triangle- clavicle, trapezius muscle, omohyoid muscle;
posterior triangle-sternocleidomastoid muscle, anterior triangle
Vessels: Temporal Artery&vein, external carotid artery, internal carotid
artery, common carotid artery, sternocleiodomastoid muscle, internal
jugular vein, external jugular vein, clavicle
8. Suggested Palpation of the Lymphnodes: Pre auricular, post
auricular, occipital, retrophayngeal (tonsillar), submaxillary
(submandibular), submental, superficial cervical chain, deep cervical
chain, suprclavicular
9. Normal and abnormal findings for Head, neck, face:
10. Normal and abnormal findings for Eyes:
1 1 . Normal and abnormal findings for Ears: Normal: Ears are
symmetric and intact, color is pink, no redness, nodules, swelling or
lesions, external auditory meatus is patent with no drainage, No pain
or tenderness on palpation of the external ear and mastoid process
Abnormal:
12. Normal and abnormal findings for Nose:
13. Normal and abnormal findings for Mouth and Throat: Normal:
Mucosa of the oral cavity is pink, intact, moist, no visible lesions,
3/32
, gums are pink, intact, moist, no visible lesions, no sensitivity of
teeth, no malocclusion;
No palpable lymphadenopathy, Trachea midline, no palpable
deviation Abnormal: 14. Describe variations in techniques and
findings: - Normocephalic, head midline, skull and facial structures
intact and symmetric, skin intact, facial movements symmetric and
smooth, no tenderness with palpation to scalp and neck, palpable
temporal arteries, TMJ full ROM with no palpable tenderness or
crepitus, neck full ROM, trachea midline, no facial or neck
lymphadenopathy
- Hair - medium brown, curly, fine texture, with receding frontal hairline.
Skull and facial features symmetric. Smiles, frowns, shows teeth, puffs
cheeks, wrinkles forehead and closes eyelids tightly (CN VII intact). Full
ROM of TMJ, no palpable crepitus. No sinus tenderness with
palpation/percussion. Two bilateral submandibular 1 cm lymph nodes,
firm, mobile, non-tender. No other noted lymphadenopathy. Trachea
midline. Full ROM of neck.
15. Discuss related Healthy People 2020 objectives: - Reduce sports
and recreational injuries.
- Reduce deaths caused by motor vehicle crashes.
- Increase the use of safety belts.
- Increase the use of helmets by cyclists.
- Reduce deaths by falls.
16. Pertinent History for Respiratory tract: - Any chronic
conditions
Asthma, COPD, CHF, DM
Exposure to new medication
