WGU Exam Prep PHYSICAL ASSESSMENT Correctly Solved 2023 Rated A+

WGU Exam Prep PHYSICAL ASSESSMENT Correctly Solved 2023 Rated A+ Subjective data *** Said by the client (S) Objective data *** Observed by the nurse (O) Order for assessment (not abdominal) *** Inspect, Palpation, Percussion, Auscultation Inspection *** Critical observation and ALWAYS first in assessment and uses all senses. Part of the hand to assess skin temperature *** back of the hand (dorsal aspect) Deep Palpation Light Palpation *** Deep: 5-8cm (2-3'') Light: 1 cm Percussion is performed in the *** wrist Bell of the stethoscope picks up *** Low pitched sounds such as heart murmurs. Diaphragm of stethoscope picks up *** High-pitched respiratory sounds General Survey *** An overall review or first impression a nurse has of a person's well being -Appearance -Body structure/mobility -Behavior Comprehensive history *** Includes: chief complaint, complete review of systems, social history and complete family past medical history Family health history includes *** three generations looking for specific patterns in genetic issues Comprehensive physical exam includes *** Body areas: head, neck, chest abdomen, genitalia, groin, buttocks, back and extremities. Organ systems: constitutional (vital signs, general appearance) eyes, ears, nose, throat, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, dermatological, neurological, psychiatric, hematological/lymphatic/immunological. BMI *** measure that can determine if a person is at risk for weight-related illness. Head circumference measurement: Birth-36 mo. *** extending a non-stretchable measuring tape around the broadest part of the child's head. Accuracy: tape is placed 3 times: right, left side, and at the mid-forehead Measure the infant's head circumference at birth and at each well-child visit up to age 2 years and then yearly up to 6 years Measuring head circumference of newborn *** 2 cm larger than chest circumference. As child ages, chest circumference becomes larger than head circumference. Chest Measurement *** Measured at the nipple line. Fontanels in a newborn - toddler *** Posterior fontanel - triangle shaped; closes 1-2 mo. Anterior fontanel - diamond shaped; closes at 9 mo.-2 yrs Vitals signs are the measurements of *** Temperature, pulse, respiration and blood pressure. Give an immediate picture of person's current state of health and well being. Irregular pulse *** always count for a full minute and record the rate and rhythm. Normal adult heart rate *** 60-100 bpm Normal adult blood pressure *** 130/85 Average Pulse and Blood Pressure in Normal Children *** Birth 6mo 1yr 2yr 6yr 8yr 10yr Pulse 100 95 Systolic 100 105 Exam of skin: inspection *** Color and uniformity of color, moisture, hair pattern, rashes, lesions, pallor and edema. Exam of skin: palpate *** temperature, turgor, lesions, edema and texture. Pale, cool moist skin can be indicative of *** Heat stroke, shock or other cardiac complications. Nevus *** mole (normal and abnormal) Order for abdominal assessment *** Inspect, Auscultation, Percussion, Palpate Ear exam of adults *** Pull the ear up and back to straighten the canal Ear exam of child *** pull the ear down and back to straighten the canal Normal color of eardrum *** shiny translucent, pearly gray Erythema *** Suppurative otitis media, purulent drainage Serous otitis media with effusion *** Dull, nontransparent gray Conductive hearing loss is due to *** Mechanical dysfunction of inner ear or middle ear Sensory-neural hearing loss is doe to the *** pathological problem of inner ear, CNS or cerebral cortex Normal hearing loss for older adults *** High-tone/pitch hearing loss Turbinates *** pink and moist Maxillary sinuses *** below zygomatic arch Frontal sinuses *** below eyebrows Sinus transillumination *** Not always definitive of disease process (shining light on the maxilla and look for orange glow on the hard palate. Hard palate *** located in anterior part of the mouth. Made of bone and is pale or whitish. Soft plate *** posterior part of the mouth; softer, more mobile and pink in color Deep cervical chain of lymph nodes lies below *** Sternomastoid and cannot be palpated without getting underneath the muscle. Inform pt that this procedure will cause discomfort. Note the size and location of any palpable nodes and whether they were soft or hard, non-tender or tender, mobile or fixed. Thyroid Gland *** Have person swallow sip of water; thyroid gland will move upward with a swallow. Note whether it is visible and symmetrical. A visibly enlarged thyroid gland=goiter. Visual Acuity *** always check visual acuity before proceeding with the rest of the exam or putting meds in pt's eyes. Allow the patient to use glasses or contact lens. Position pt **20 FEET in front of the Snellen eye chart (or hold a Rosenbaum pocket card at 14 inches). -Have pt cover one eye at a time with an **opaque card. Visual Fields - Screen Visual Fields by Confrontation Tests Peripheral Vision *** 1. Stand 2 feet in front of the patient and have them look into your eyes. 2. Hold your hands to the side half way between you and the patient. 3. Wiggle the fingers on one hand. 4. Ask the patient to indicate which side they see your fingers move. 5. Repeat two or three times to test both temporal fields. 6. If an abnormality is suspected, test the four quadrants of each eye while asking the patient to cover the opposite eye with a card Extraocular Movement (EOM) Method Tests which Cranial Nerves? *** 4 C's: Convergence Corneal Light Reflex Cranial Nerve 3,4,6 6 Cardinal Directions (H or Cross) 1. Stand or sit 3 to 6 ft in front of the patient. 2. Pt to follow your finger with their eyes without moving their head. 3. Check gaze in the six cardinal directions using a cross or "H" pattern. 4. Convergence-moving your finger toward the bridge of the patient's nose. 5. Pause during upward and lateral gaze to check for nystagmus (involuntary eye movement which differs in each eye). 6. Tests CN 3, 4, and 6 -Corneal light reflex PERRLA *** "Pupils Equal Round Reactive to Light and Accommodation." If you did not specifically check accommodation reaction use the term PERRL. Accommodation: a) Hold your finger about 10cm from the patient's nose. b) Ask them to alternate looking into the distance and at your finger. c) Observe the pupillary response in each eye. Ophthalmoscopic Exam *** 1. Use left hand and left eye to examine the patient's left eye. Use your right hand and right eye to examine the patient's right eye. Place free hand on the pt's shoulder for better control. Ask the pt to stare at a point on the wall or corner of the room. 5. Look through the ophthalmoscope and shine the light into the patient's eye from about two feet away. You should see the retina as a "red reflex." Follow the red color to move within a few inches of the patient's eye. 6. Adjust the diopter dial to bring the retina into focus. Find a blood vessel and follow it to the optic disk. Use this as a point of reference. 7. Inspect outward from the optic disk in at least four quadrants and note any abnormalities. 8. Move nasally from the disk to observe the macula. 9. Repeat for the other eye. 10. Normal color should be creamy yellow-orange to pink. A-P (anterior-posterior) diameter vs. transverse diameter of Chest *** A-P should be Transverse in adults; 1:2 - 5:7 Elevated A-P size = barrel chest, may be COPD in adult; normal in children Elevated A-P chest size *** Barrel chest, may be COPD in adult and normal in children. Percussion in chest exam *** Hyper-extend the middle finger of one hand and place the distal interphalangeal joint firmly against the pt chest.With the end of the opposite middle finger use a quick flick of the wrist to strike the first finger. Findings: normal, dull or hyperresonant Hyperresonant found with percussion *** Emphysema or Pneumothorax Adventitious Breath Sound: CRACKLES *** (Rales) High pitched, discontinuous sounds similar to the sound produced by rubbing your hair between your fingers. Adventitious Breath Sound: WHEEZES *** high pitched and "musical" in quality. Stridor is an inspiratory wheeze associated with upper airway obstruction (croup). Adventitious Breath Sound: RHONCHI *** "snoring" or "gurgling" Any extra sound that is not a crackle/wheeze is probably rhonchi. Low pitched. Tactile Fremitus *** 1. Ask the patient to say "ninety-nine" several times in a normal voice 2. Palpate using the ball of your hand. 3. You should feel the vibrations transmitted through the airways to the lung. 4. Increased tactile fremitus suggests consolidation of the underlying lung tissues. Egophony *** 1. Ask the patient to say "ee" continuously. 2. Auscultate several symmetrical areas over each lung. 3. You should hear a muffled "ee" sound. If you hear an "ay" sound = "E - A" or egophony. Pulse pressure *** Difference between the systolic and diastolic blood pressure reading. Bruit *** turbulent blood flow through carotid artery; blowing swishing sound = narrowing of the vessel Point of maximal impulse (PMI or apical pulse). *** located in the 4th or 5th intercostal space just medial to the midclavicular line and is less than the size of a quarter. Thrill *** palpable vibration. It feels like the throat of a purring cat. Capillary Refill *** Press down firmly on the patient's finger or toe nail so it blanches then release. Capillary refill times greater than 2-3 seconds suggest peripheral vascular disease, arterial blockage, heart failure or shock. Aortic area *** Listen with diaphragm at the right 2nd interspace near the sternum Pulmonic area *** Listen with diaphragm at the left 2nd interspace near the sternum Tricuspid area *** Listen with diaphragm at the left 3rd, 4th, and 5th interspaces near the sternum Mitral area *** Listen with diaphragm at the apex (PMI) Normal Degrees of fingernails Normal, curved, early clubbing *** a) Normal = 160 degrees b) Curved = 160 degrees or less c) Early clubbing = 180 degrees Edema *** Scale Level of pitting Indentation Swelling of leg 1+ Mild, slight, not noticeable 2+ Moderate, subsides rapidly 3+ Deep, short time, leg looks swollen 4+ Very deep, long time, grossly swollen Cyanosis *** (blue color) of feet and hands Abdominal assessment starts *** RLQ over ileocecal valve Inspect adult abdomen contour *** flat Inspect newborn abdomen contour *** protuberant and soft Inspect child abdomen contour *** symmetric and slightly rounded Percussion of abdomen *** clockwise in all four quadrants starting in RLQ. Tympanic or dull sounds on abdominal percussion *** Tympany present over most of abdomen in supine position. Unusual dullness =underlying abdominal mass or full bladder. Palpation of the Liver Standard and Alternate Method *** Standard Method: 1. Place your fingers just below the right costal margin and press firmly. 2. Ask the patient to take a deep breath. 3. You may feel the edge of the liver press against your fingers. Or it may slide under your hand as the patient exhales. A normal liver is not tender. 4. Usual location is about 1-2 cm. below right costal margin. Alternate Method This method is useful when the patient is obese or when the examiner is small compared to the patient. 1. Stand by the patient's chest. 2. "Hook" your fingers just below the costal margin and press firmly. 3. Ask the patient to take a deep breath. 4. You may feel the edge of the liver press against your fingers. Measurement of Abdominal girth *** measure the distance around the abdomen at the level of the belly button (navel). Rebound Tenderness (Blumberg Sign) Test *** Test for peritoneal irritation Press deeply on abd then quickly release pressure. Pain during release = rebound tenderness Costovertebral Tenderness *** Test for renal disease. Use the heel of your closed fist to strike the patient firmly over the costovertebral angles and compare left and right side. Obturator sign *** Test for appendicitis. Raise the patient's right leg with knee flexed, rotate the leg internally at the hip. Increased abdominal pain indicates a positive obturator sign. Musculoskeletal system always begin with *** Inspection, Palpation and ROM (except abdomen) Scoliosis *** lateral curvature of spine with unequal leg length. Minimal with young children which resolves with change of position. More common as a concern in adolescents. Kyphosis *** "hunchback"; over-curvature of the thoracic vertebrae Knock knees *** knees together when standing. Normal to age 7 years; abnormal older. Bow legs *** normal to age 3 years; abnormal older. Toe walking *** usually stops by 3 months after start of walking. Phalen's Test (Median Nerve) *** 1. Ask the patient to press the backs of the hands together with the wrists fully flexed (backward praying). 2. Have the patient hold this position for 60 seconds and then comment on how the hands feel. 3. Pain, tingling, or other abnormal sensations in the thumb, index, or middle fingers strongly suggest carpal tunnel syndrome. Tinel's Sign (Median Nerve) *** 1. Use your middle finger or a reflex hammer to tap over the carpal tunnel. 2. Pain, tingling, or electric sensations strongly suggest carpal tunnel syndrome. Homan's Sign *** pain in the calf of the leg upon dorsiflexion of the foot with the leg extended that is diagnostic of thrombosis in the deep veins of the area FABER Test (Hips/Sacroiliac Joints) *** Flexion, ABduction, and External Rotation of the hip. This test is used to distinguish hip or sacroiliac joint pathology from spine problems. 1. Ask the patient to lie supine on the exam table. 2. Place the foot of the effected side on the opposite knee (this flexes, abducts, and externally rotates the hip). 3. Pain in the groin area indicates a problem with the hip and not the spine. 4. Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest. 5. Pain in the sacroiliac area indicates a problem with the sacroiliac joints. Mental status should be assessed while doing health history and includes *** level of consciousness, facial expression, body language, speech, cognition and functioning. Cerebral *** mental status Cerebellum *** gait, coordination, balance, etc. List 12 Cranial Nerves link to visual picture II optic nerve (2 eyes to see) III oculomotor nerve (3,4,6 makes my eyes do tricks) IV trochlear nerve V trigeminal nerve VI abducens nerve VII facial nerve VIII vestibulocochlear/auditory nerve (8is hearing AIDE) IX glossopharyngeal nerve X vagus nerve XI accessory/spinal nerve XII hypoglossal nerve (tongue movement) Oh Oh Oh To Touch And Feel A Girl's V, Ah Heaven Cranial Nerve I Olfactory *** 1. Sensory nerve: Tests sense of smell 2. Not routinely tested unless indicated. Cranial Nerve II Optic *** 1. Sensory nerve: vision 2. Test Visual Acuity: Use Snellen eye chart or a Rosenbaum pocket card at a 14 inch "reading" distance). 3. Screen Visual Fields by Confrontation. use PERRLA Cranial Nerve III *** Oculomotor 1. Mixed nerve: (A) Motor: controls extraocular movements (EOM), opening eyelids; (B) Parasympathetic: pupil constriction, iris shape 2. Observe for Ptosis (drooping eyelid) 3. Test Extraocular Movements Process is on page 11 under "Examination of Eye" 4. Test Pupillary Reactions to Light. use PERRLA IV Trochlear *** 1. Motor nerve: inward and down movement of eye 2. Test Extraocular Movements (Inward and Down Movement). V Trigeminal *** 1. Mixed nerve. (A) Motor: muscles of mastication; Move jaw side to side (B) sensory: face, scalp, mouth, nose 2. Test Temporal and Masseter Muscle Strength a. Ask patient to both open their mouth and clench their teeth. b. Palpate the temporal and masseter muscles as they do this. 3. Test the Three Divisions for Pain Sensation a. Explain/ Use a suitable sharp object to test the forehead, cheeks, and jaw on both sides. c. Substitute a blunt object occasionally and ask the patient to report "sharp" or "dull." d. If you find and abnormality then: Test the three divisions for temperature sensation with a tuning fork heated or cooled by water. e. Test the three divisions for sensation to light touch using a wisp of cotton. 4. Test the Corneal Reflex (normally not checked unless specific concerns) a. Ask the patient to look up and away. b. From the other side, touch the cornea lightly with a fine wisp of cotton. c. Look for the normal blink reaction of both eyes. d. Repeat on the other side. e. Use of contact lens may decrease this response. VI Abducens *** 1. Motor: lateral eye movement 2. Test Extraocular Movements (Lateral). Process is on page 11 under "Examination of Eye" VII Facial *** 1. Mixed: (A) Motor: muscles used for facial expressions, close eye and mouth; (B) Sensory (sense of taste in the front 2/3 of tongue; (C) Parasympathetic: saliva and tear secretion 2. Sense of taste not usually checked unless specific concerns 3. Observe for Any Facial Droop or Asymmetry a) Ask Patient to do the following, note any lag, weakness, or asymmetry: Raise eyebrows b) Close both eyes to resistance c) Smile d) Frown e) Show teeth f) Puff out cheeks 4. Test the Corneal Reflex (See C.N. V above) VIII Acoustic *** 1. Sensory: Hearing and Equilibrium 2. Initial test: a) Face the patient and hold out your arms with your fingers near each ear. b) Rub your fingers together on one side while moving the fingers noiselessly on the other. c) Ask the patient to tell you when and on which side they hear the rubbing. d) Increase intensity as needed and note any asymmetry. e) Test hearing with normal voice and whispers 3. If abnormal, proceed with the Weber and Rinne tests. 4. Test for Lateralization (Weber) -Use a 512 Hz or 1024 Hz tuning fork. c) Start the fork vibrating by tapping it on your opposite hand. d) Place base of the tuning fork firmly on top of the pt's head. e) Ask pt where the sound appears to be coming from (normally in the midline). f) Normal is to hear equally in bone ears. If louder in one ear, it is abnormal. Abnormal indicates conductive hearing loss in that ear or sensory hearing loss in opposite ear. **5. Compare Air and Bone Conduction (Rinne) b) Use a 512 Hz or 1024 Hz tuning fork. c) Start the fork vibrating by tapping it on your opposite hand. d) Place base of tuning fork against mastoid bone behind the ear. e) When pt no longer hears the sound, hold the end of the fork near the pt's ear (air conduction is normally greater than bone conduction). f) Normal (positive result) = hearing sound still once moved behind mastoid IX Glossopharyngeal *** Mixed: motor: Swallowing, Sensory: taste on posterior tongue, gag reflex Parasympathetic: parotid gland X Vagus *** 1. Mixed : (A) Motor: pharynx and larynx (swallowing and talking) (B) Sensory: general sensation from carotid body, carotid sinus, pharynx, viscera; (C) parasympathetic: carotid reflex. Slows heart rate. 2. Listen to the patient's voice, is it hoarse or nasal? 3. Ask patient to swallow 4. Ask patient to Say "Ahhh". Watch the movements of the soft palate and the pharynx. 5. Test gag reflex. On an unconscious or uncooperative patient, stimulate the back of the throat on each side. It is normal to gag after each stimulus. XI Spinal Accessory *** 1. Motor: trapezius and sternomastoid muscles 2. From behind, look for atrophy or asymmetry of the trapezius muscles. 3. Ask patient to shrug shoulders against resistance. 4. Ask patient to turn their head against resistance. Watch and palpate the sternomastoid muscle on the opposite side. XII Hypoglossal *** 1. Motor: movement of tongue 2. Listen to the articulation of the patient's words. 3. Observe the tongue as it lies in the mouth 4. Ask patient to: Protrude tongue 5. Move tongue from side to side Key milestones in children *** 2 months smiles recognizes parents 4 months babbles few words 5 months sits up with support 6 months grasps things; may hold bottle 7 months begins crawling 8 months sits without support; stranger anxiety 12 months walks alone MEMORY TIP: SMILES AT PARENTS BABBLES SITS WITH SUPPORT (HIGH 5) WITH 6 BOTTLE CRAWLS AND 8 AND SIT WITH STRANGER WALKS Romberg Cerebellar Test *** 1. Be prepared to catch the pt if they are unstable. 2. Ask pt to stand with the feet together and eyes closed for 5-10 seconds without support. Test is Positive if Unstable = vestibular or proprioceptive problem Deep Tendon Reflexes *** 1. pt must be relaxed and positioned properly 2. Reflex response depends on the force of your stimulus. Use no more force than you need to provoke a definite response. 3. Reflexes can be reinforced by having the pt perform isometric contraction of other muscles (clenched teeth). 4. Exaggerated hyperactive reflexes in a pregnant woman may be related to pre-eclampsia. 5. Reflexes should be graded on a 0 to 4 "plus" scale: Deep Tendon Reflexes Grading Scale *** Grade Description 0 Absent 1+ Hypoactive 2+ **Normal** 3+ Hyperactive without clonus. May indicate disease but also may be normal 4+ Hyperactive with clonus. Indicative of disease Clonus *** rapid rhythmic contractions of same muscle Brisk or greater than 2+ DTRs and clonus may be associated with elevated BP and cerebral edema in the preeclamptic woman. Plantar Response (Babinski) *** 1. Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key. 2. Note movement of the toes, normally flexion (withdrawal). 3. Extension of the big toe with fanning of the other toes is abnormal in other than a young child. This is referred to as a positive Babinski 4. **Positive Babinski is normal to age 24 months. Graphesthesia *** blunt end of a pen or pencil, draw a large number in the patient's palm. Ask pt to identify number. Stereognosis *** Place familiar object in patient's hand (coin, paper clip). Ask pt to identify object. Two point discrimination *** Use in situations where more quantitative data are needed following the progression of a cortical lesion. Use open paper clip to touch the patient's finger pads in two places at same time and then alternate irregularly with one point touch. Find minimal distance at which the patient can discriminate. Routine pediatric neuro testing includes *** Plantar (Babinski) normal to age 24 months Moro (startle) normal to about 4 months Rooting (sucking when cheek or lip is touched) birth to about 3-4 months Palmar grasp birth, stronger at 1-2 months, gone by 3-4 months. Prostate screening *** 1. Digital exam - recommended annually. **Hemocult any specimen. 2. PSA - lab test. Recommendations vary - every 1-2 years Testicular self exam *** 1. Start age 15 on 2. Remember: Timing: 1 x month Shower - warm water Examine - should be no lumps Men should also perform BSE but are less likely to have routine mammograms Mammogram *** women ages 40 years and older should perform BSE, with an annual mammogram Breast Self Exam (BSE): *** 1. Perform monthly right after menses or day 4-7 of cycle 2. include raising arms to look for retraction Pap smear *** Tests for cervical cancer 1. Specimens taken from (in order): Vaginal pool, Cervical scrape, Endocervical specimen. 2. Post hysterectomy and cervix removal - scrape from end of vagina and cervical pool.