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2024-2025 NURS190 Physical Assessment Final Exam (30 Solved Assessments)

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    NURS 190 Physical Assessment Final latest 2024/2025 EXAM Inspection technique (3): ● FIRST technique with general survey ● General survey: ○ Observing mobility / gait, physical appearance, general wellness/health, mood & behavior (facial expressions, interactions), mental status (observing patient’s body language and response when asking questions) ● Do it the SAME WAY every time → less likely to forget something ● Do not rush it , especially with anxious patients ○ Make sure the patient is comfortable ○ Temperature in the room is suitable for the patient ● Make sure that you have everything that you need → so that the patient has confidence in you ● Know normal vs abnormal when surveying appearance & symmetry ○ Compare ANYTHING that has a pair ○ Eyes - level, equal, is there eyelid drooping? ○ Smile - is there a droop? ○ Always compare the two sides to ensure that there is no abnormality between the two sides ● Listen for natural sounds ○ Abnormal sounds : wheezing, labored breathing, crepitus during ROM ● Detect abnormal odors: ○ CDIFF, alcohol on a patient, acetone / sugary breath ● Try not to assume anything ! → use critical thinking! ○ Ex: someone with low blood sugar or issues with hypoxia can appear intoxicated ● Know your normal values: ○ Blood pressure, HR, RR, O2 sats, temperature ○ For each age levels ■ Infants: must faster RR than elderly Percussion technique (3) ● Types: ○ Direct percussion - tapping body with fingertips of dominant hand

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    ■ For a small infant → direct percussion on the chest ■ Adult → on the sinuses on the face ○ Blunt percussion - place palm of nondominant hand flat against the surface and strike it with closed - fist dominant hand ■ Used to assess the kidneys → assessing for pain / tenderness

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    (UTI) ○ Indirect percussion - most commonly used ■ Plexor = hammer or tapping finger ■ Pleximeter = device or surface that accepts the tap ● Sounds: ○ Intensity of amplitude : softness or loudness ○ Pitch or frequency: high or low (vibrations per second) ○ Duration : length of time ○ Quality : recognizable overtones or drumlike sounds ● Tympany - sound heard over stomach or intestines ○ Loud, high - pitched, drum - like tone ● Resonance - normal sound heard over lungs ○ Loud, low - pitched, hollow tone ● Hyperresonance - air trapped in lungs ○ Abnormally loud, low tone of longer duration than resonance ■ COPD, trauma or lung collapse ● Dullness - over solid body organs (liver) ○ High - pitched tone, soft and short ● Flatness - over solid tissue, muscle, or bone ○ High - pitched tone, very soft & shorter than dullness ■ Ex: ribs Skin assessment (5) ● Life span considerations: ○ Infants and children ■ Newborn skin → covered with vernix caseosa ■ Infants have thin, soft, skin and free of hair ■ Milia and stork bites - common, harmless markings in newborns ■ Mongolian spots - gray, blue or purple spots in sacral and buttocks area ● Fade by age 3 ● Try not to confuse it with possibility of abuse → ask the parent “is this something that has been here since birth?” ■ Poor temperature regulation → do not secrete from glands ○ Pregnant female ■ Skin pigmentation increases → in areolae, nipples, vulva, perianal area ● Development of melasma and linea nigra down the abdomen ● Resolve itself after pregnancy ■ Hormonal changes→ cause oil and sweat glands to become hyperactive ● Acne worsens in 1st trimester ■ Hair may fall out during months 1 - 5 ○ Older adult ■ Skin elasticity decreases with aging

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    ■ Sebum production decreases → causes dryness ● More prone to skin breakdown ■ Perspiration / sweating decreases ■ Decrease in melanin production → result in gray hair ■ Nails become thicker and more brittle due to decreased amount of circulation ■ Hair thins because of decrease of hair follicles ■ Liver spots, hyperpigmented freckles, increased amount of skin tags ● Psychosocial considerations: ○ Stressed induced illness: ■ Trichotillomania - hair twisting & pulling ■ Nail biting ■ Visible skin disorders in relation to self - esteem / body image ● Cultural and environmental considerations: ○ Socioeconomic status ■ Not able to go to the doctor because of finances ○ Home environment ■ Are they homeless? → if so, could be more likely to develop skin cancer due to outside exposure ○ Means of employment ■ If they work outside → important to know ■ Do not assume bad hygiene!! → could be from work ○ Changes in skin color → may be more difficult to detect in patients with dark skin ○ Dry skin does not necessarily indicate dehydration ○ Skin response to stressors differ from person to person ■ Autoimmune disorders ○ Differences in hair color and texture vary from different cultural groups ○ Prolonged immersion of hands in water can cause paronychia - reddened cuticles causing infection ○ Table 13.2 (variations) 31:28 ● Focused interview - questions related to: ○ Notice any smells / foul odors ○ Changes in color → oxygenation issues or perfusion ○ Sweating → fever, being in the sun too long, excessive sweating ○ Skin : ■ In general ■ Illness or infection ■ Symptoms, pain, behaviors ■ Age ■ External environment ○ Hair : ■ In general ■ Infants and children

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    ○ Nails : ■ In general ■ Infants and children ■ Pregnant females ■ Older adult ● Color variations in light and dark skin ○ Pallor - loss of color in skin due to absence of oxygenated hemoglobin ■ Light skin: ● White skin loses rosy tones ● Yellow tone appears more yellow ■ Dark skin: ● Black skin loses its red undertones and appears ash - gray ● Brown skin becomes yellow - tinged ○ Absence of color - loss of pigment ■ Albinism - white/pale blond hair and pink irises ■ Vitiligo - very noticeable as patchy milk - white areas ■ Tinea - appears patchy areas paler than surrounding skin ○ Cyanosis - blue color in skin due to inadequate tissue perfusion ■ Light skin: ● Skin, lips, mucous membranes look blue - tinged; nail beds are blue ■ Dark skin: ● May appear a shade darker ● May be undetectable except for lips, tongue, oral mucous membranes, nail beds, and conjunctivae ○ Reddish blue tone - ruddy tone due to increased hemoglobin and stasis of blood ■ Light skin: reddish purple hue ■ Dark skin: difficult to detect; normal skin may appear darker in some patients ○ Erythema - redness of the skin due to increased visibility of normal oxyhemoglobin ■ Light skin: local inflammation and redness ■ Dark skin: hard to detect; inflammation appear purple or darker than surrounding skin ○ Jaundice - yellow undertone due to increased bilirubin ■ Generalized; visible in sclera, oral mucosa, hard palate, fingernails, palms of hands, and soles of the feet Skin lesions (5) ● Primary lesions: ○ Macule and patch - flat, nonpalpable change in the skin color ■ Macule : Smaller than 1 cm ■ Patch : larger than 1 cm ○ Papule and plaque - elevated, solid palpable masses with a circumscribed

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    border ■ Papule : smaller than 0.5 cm ■ Plaques : groups of papules that form lesions larger 0.5 cm ○ Nodule and tumor - elevated, solid, hard or soft palpable mass extending deeper into the dermis ■ Nodules : smaller than 2 cm ■ Tumors : may have irregular borders and are larger than 2 cm ○ Vesicle and bulla : elevated, fluid - filled, round or oval - shaped, palpable masses with thin, translucent walls and circumscribed borders ■ Vesicles : smaller than 0.5 cm ■ Bullae : larger than 0.5 cm ○ Pustule - elevated, pus - filled vesicle or bulla with a circumscribed border ■ Size varies ○ Wheal - an elevated, often reddish area with an irregular border caused by diffuse fluid in tissues ■ Size varies ○ Cyst - elevated, encapsulated, fluid - filled or semisolid mass originating in subcutaneous tissue or dermis ■ Usually 1 cm or larger ● Vascular lesions: ○ Ecchymosis - flat, irregular shaped lesion of varying size with no pulsation; does not blanch with pressure → BRUISE ■ In light skin : bluish, purple mark that changes yellow ■ Brown skin : varies from blue to deep purple ■ Black : darkened area ○ Hemangioma - bright, red raised lesion about 2 - 10 cm in diameter that does not blanch with pressure; present at birth or within few months of birth and typically disappears by age 10 ■ Cluster of immature capillaries ○ Cullen sign - periumbilical; could indicate internal bleeding in abdomen ○ Grey turner sign - flank area; could indicate bleeding into peritoneum, pancreatitis, etc. ○ Hematoma - raised, irregularly shaped lesion similar to ecchymosis except that it is elevated and looks like swelling ■ Caused by leakage of blood into the skin and subcutaneous tissue ○ Petechiae - flat, red or purple rounded “freckles”; approximately 1 - 3 mm in diameter; pinpoint lesions ■ Difficult to detect in dark skin and do not blanch ○ Purpura - flat, reddish - blue, irregularly shaped extensive patches of varying size ○ Port - wine stain - flat, irregular shaped lesion ranging from pale red to deep purple - red ■ Color deepens with exertion, emotional response, or exposure to extreme temperatures ■ Present at birth and typically does not fade

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    ○ Spider angioma - flat, bright red dot with tiny radiating blood vessels ranging in size from a pinpoint to 2 cm; blanches with pressure ○ Venous lake - soft, compressible, slightly elevated vascular lesion; color typically ranges from dark blue to purple ● Infectious lesions: ○ Tinea - fungal infection affecting the body, scalp, or feet ■ Body = tinea corporis ■ Scalp = tinea capitis ■ Feet = tinea pedis (athlete’s foot) ○ Measles (Rubeola) - highly contagious viral disease that causes a rash of red to purple macules or papules that begins on face, then progresses over the neck, trunk, arms, and legs ■ Lesions do not blanch ■ Oral mucosa may demonstrate tiny, white spots that look like grains of salt ○ Varicella (chicken pox) - mild infections disease caused by primary infection with the varicella zoster virus; small, red, fluid - filled vesicles usually on the trunk from which the rash progresses to the face, arms, and legs ■ Erupt over several days forming pustules, then crusts ■ Cause intense itching ○ Rubella - highly contagious disease caused by rubella virus; typically begins as pink, papular rash that is similar to measles but paler ■ Skin lesions begin on the face and then spread over the body ○ Herpes simplex → cold sores ○ Herpes zoster → shingles ■ Clusters of small vesicles that form on the skin along the route of sensory nerves ○ Impetigo - contagious, bacterial skin infection that usually appears on the skin around the nose and mouth ■ Lesions may begin as barely perceptible patch of blisters that break, exposing red, weeping area beneath ■ Tan crust forms over the area ■ Common in children Nail abnormalities (2) ● Caused by : genetic factors, infectious disease processes, traumatic injuries ● May also provide clues to presence of underlying disease process involving other body systems ● Spoon nails / koilonychia - can be a sign of anemia, especially iron - deficiency anemia ● Paronychia - soft tissue infection around a fingernail at the cuticle causing inflammation ● Beau lines - occur after illness, injury to the nail, eczema around the nail, during chemotherapy for cancer

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    ● Splinter hemorrhage - can be a manifestation of connective tissue condition such as lupus or scleroderma; appear as reddish - brown spots in the nail ● Onycholysis - painless separation of the nail from the nail bed; fungal infection causing the nails to thicken and lift off nail bed ● Clubbing - nails appear convex and wide; angle is greater than 160 degrees ○ Poor oxygenation Subjective data (3) Equipment (2) ● Various instruments that help in visualizing, hearing, and measuring data ○ Stethoscope, otoscope, penlight, doppler ultrasound, ophthalmoscope, reflex hammer, BP machine (table 9.1) ○ Before physical assessment: ■ Gather all equipment ! ■ Organize it ■ Place within easy reach for availability ○ Stethoscope - auscultates body sounds such as BP, heart sounds, respirations, bowel sounds ■ Used on exposed skin!! ■ Components : ● Binaurals - pointed toward face ● Flexible tubing ● End piece ○ Bell - low - pitched sounds (murmurs) ○ Diaphragm - best for high - pitched sounds (lung sounds, bowel sounds, normal heart sounds) ■ Does not “amplify” sound!! → just isolates them ○ Doppler ultrasonic stethoscope - detect sounds that are difficult to hear with regular stethoscope ■ Fetal heart sounds, peripheral pulses ■ Use gel → isolates sound waves better ○ Ophthalmoscope - inspects internal eye structures ■ Components: ● Handle & head ● Used to see anterior structure of the eye: ○ Large aperture: dilated pupils ○ Small aperture : constricted pupils ○ Red - free filter: help to see optic disc ○ Grid: if there is any lesions → help to locate size of lesions ○ Slit

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    ○ Otoscope - examines external ear structures ■ Need to make sure you’re using the right size! ● Too large or too small can prevent you from seeing anything ■ Components : ● Handle, light, lens, specula of various sizes ■ Normal appearance of tympanic membrane: clear, pearl colored; no purulent fluid ○ Wood lamp → used for fungal infection General survey (2) ● Observing mobility / gait, physical appearance ● General wellness/health ● Mood & behavior (facial expressions, interactions) ● Mental status (observing patient’s body language and response when asking questions) ● Open - ended - intentionally general and encourage the patient to provide additional information ○ Can be during actual assessment ○ H & P ○ What kind of changes have you noticed that have occurred with your skin? ○ “Tell me more about that…” ● Close - ended - quick and simple, yes or no question ○ Do you have allergies? Are you taking any medication? Neck assessment (1) ● Inspection of skin ● Testing range of motion ● Observation of carotid arteries and jugular veins ● Palpation of trachea ● Inspection, palpation, and auscultation of thyroid gland Eye assessment (5) ○ General : “Describe your vision today…” ○ Consider expectations based on: ■ Age ■ Race ■ Environment ■ Health practices ■ Past & current problems / therapies ○ Ask about any infections, surgeries, or injuries ○ Consider patient’s ability to participate → based on any problems stated that are significant ○ Symptoms, pain and behaviors ○ “When was your last eye exam?” → especially in an older client, diabetic

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    patients ● Lifespan considerations: ○ Infants and children: ■ Did the mother have a vaginal infection? ■ Was the child full term or premature? If premature, how early? ● Could have been over oxygenated in NICU causing visual problems ○ Pregnant female: ■ Any changes in vision? ■ Reassure mother that it is temporary → will return by 6 months ○ Older adult: ■ Do you have any dryness? ● If the individual OVER USES eye drops → the lacrimal glands are less likely to continue to produce tears ■ Any problems with night vision? → may affect their daily living ○ Internal environment: ■ Ask whether or not the patient is taking any medications that could affect vision ■ Is there a family history of eye problems? ● Glaucoma IS inherited ● Cataracts are not genetic ○ External environment: ■ Have they been exposed to any eye irritants? ■ Do they work in an environment that can cause eye irritants? ■ Are they using safety equipment to protect eye? ● Eye assessment (5) ○ Inspection : ■ What does the sclera look like? ● Is it a normal white color? ● Is there jaundice? → can indicate liver problems ■ Looking for redness, drainage ○ Tests : ■ Snellen Tests (distance) - tests for visual acuity ● Tests for cranial nerve II ● Stand 20 feet away and cover one eye ○ Read the smallest line they can possibly read ○ If patient reads half or more of the line wrong → move up to the next highest level ● First number → 20 feet away from Snellen ○ NEVER CHANGES ● Second number → how far away someone with normal vision will see what you see ● Ex: 20/40 : you’re standing at 20 feet and seeing what a person

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    with normal vision could see at 40 feet ■ Jaeger / Rosenbaum - near vision ● 12 - 14 inches away ■ Confrontation test - peripheral vision ● Your eye AND the patient eye are covered on the opposite sides (same eye when facing each other) ● Something is coming into view → if the patient sees it at the same time that you do, they have normal vision ■ Cardinal fields of gaze - extraocular muscles ● Cranial nerves 3, 4, 6 ● Assessing for any deviation in vision ■ Cover / uncover: ● Normal = no deviation ● Could have a slight deviation → but will not see it until you cover / uncover the eye ■ PERRLA - pupils are equal, round, and reactive to light and accommodation ● Pupil size are equal: between 3 and 6 ● Reactive to light : constriction when light is shined at them ● Accommodation: eyes converge and pupils constrict when looking at something close up ■ Consensual constriction - pupil constricts when a light is shone in the eye ○ Palpation: ■ Warmth, tenderness, edema, etc ○ Ophthalmoscope - looking at the internal parts of the eye (pupils) ■ Looking at the fundus, macula ■ Want to see a red reflex → light reflection from the retina ■ Looking for normal blood vessels: ● Are the constricted or enlarged? ■ Are there any lesions? ■ White spots on the macula? ■ Pale conjunctiva → can indicate types of anemia ■ Parts: ● Small aperture - constricted pupils ● Large aperture - pupils that are dilated ● Grid aperture - to detect a presence of any kind of lesion Eye abnormalities (5) ● Abnormalities of the eyelids: ○ Blepharitis - general inflammation / redness of the eyelids ■ Staphylococcal infection leads to red, scaly, and crusted lids

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    ■ The eye burns, itches, and tears ○ Basal cell carcinoma - usually seen on the lower lid and medial canthus ■ Papular appearance ○ Chalazion - firm, nontender nodule on the eyelid arising from infection of the meibomian gland ■ Not painful unless inflamed ○ Hordeolum - also called a stye ■ Result of staphylococcal infection of hair follicles on the margin of the lids ■ Affected eye is swollen, red, and painful ○ Entropion - inversion of the eyelid and lashes caused by muscle spasm of the eyelid ■ Friction from lashes can cause corneal irritation ○ Ectropion - eversion of the lower eyelid caused by muscle weakness exposing the palpebral conjunctiva ○ Ptosis - drooping of the eyelid ■ Occurs with cranial nerve damage or systemic neuromuscular weakness ○ Periorbital edema - swollen, puffy eyelids ■ Occurs with crying, infection, trauma, systemic problems (kidney failure, heart failure, allergies) ○ Exophthalmos - abnormal protrusion of one or both eyeballs ■ Usually occurs secondary to Grave’s disease ● Lipids are being deposited in the back of the eye and pushes it out ■ Can also be caused by infectious disease, certain forms of cancer and other disorders ● Abnormalities of the eye: ○ Conjunctivitis - infection of the conjunctiva usually due to bacteria or virus ■ Pink eye ○ Iritis - serious disorder characterized by redness around the iris and cornea ■ Decreased vision and deep, aching pain ■ Pupil is often irregular ○ Subconjunctival hemorrhage - results from ruptured blood vessel that leads to blood accumulation in the subconjunctival space ■ Caused by trauma, anticoagulant therapy, hypertension, elevated venous pressure ○ Pterygium - non - cancerous growth that develops from the conjunctiva and extends onto the sclera ■ May also extend to the cornea ■ Can cause problems with vision ○ Hyphema - collection of blood in the anterior chamber of the eye that is most often caused by blunt trauma to the eye ■ Can also be caused by eye surgery, blood vessel abnormalities, medical problems ○ Acute glaucoma - result of sudden increase in intraocular pressure resulting from

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