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NSG 500 : ADVANCED HEALTH ASSESSMENT EXAM II (COMLETE & ACCURATE) WILKES
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- Wilkes University
NSG 500 : ADVANCED HEALTH ASSESSMENT EXAM II (COMLETE & ACCURATE) WILKES
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NSG 500 : ADVANCED HEALTH ASSESSMENT EXAM II (COMLETE & ACCURATE)WILKES
1:4 Normal resp rate to HR ratio
2-3 cm Lower border of liver should drop with deep breath
20/20 vision distance person is from chart / what a normal person can see at 20 feet
Abnormal breath sounds crackles, rhonchi, wheezes, friction rub, mediastinal crunch
Decreased diaphragmatic excursion indicates COPD/emphysema, restrictive lung disease
Abnormal findings of aging ears, nose, throat presbycusis, conductive hearing loss
Abnormal findings of aging eyes macular degeneration (decreased central vision, use Amsler
grid), decreased accommodation (focusing power) called presbyopia, cataracts d/t compressed
fibers
Abnormal findings of aging HEENT neck pain, crepitus, dizziness, jerkiness, or limitation of
movement.
Abnormal respirationstachypnea, bradypnea, hyperpnea, Kussmaul, hypopnea, Cheyne-Stokes
absent bowel sounds no sounds after 5 minutes of continuous listening - associated with
abdominal pain and rigidity and is a surgical emergency
Adult Otoscopic exampull auricle upward and back, should be uniform pink, hair on outer 2/3,
some cerumen; no lesions, discharge or foreign bodies present; TM should be translucent, pearly
grey visible landmarks (umbo, handle of malleus, and light reflex, concavity at umbo
Air-conducted should be heard 2x as long as bone conducted.
Altered resonance bronchophony, whispered pectoriloquy, egophony
Anterior-pointing cervix indicates retroverted uterus
Aortic aneurysm A prominent lateral pulsation suggests
Aortic regurgitation murmur Heard w/ diaphragm, pt. sitting and leaning forward
Austin-Flint murmur Heard w/ bell at apex, severe aortic regurge murmur
Ejection click Heard in second intercostal space
Aortic stenosis murmur Heard over aortic area; ejection sound at second right intercostal
border
,aortic valve area First, auscultate the in the second right intercostal space at the right
sternal border.
Appendicitis special tests rebound tenderness, Rovsing's sign, Iliopsoas sign, obturator's sign,
cutaneous hyperesthesia, markle test
Areolae and nipples inspect for shape, color, texture, eversion, retraction/deviation
Areolae texture should be smooth except for nontender Montgomery tubercles.
Arterial embolic disease pain, paresthesia, nail bed hemorrhages
Ascites tests fluid wave, shifting dullness
Assess for tactile fremitus pt. repeats "99." (Mickey Mouse for kids) Systematically palpate
chest front/back/sides w/ a light, firm touch and feel for chest wall vibration. Should be
symmetrical.
Auscultate chest/lungs use stethoscope diaphragm, move systematically from apex to
base, compare sides, listen through inspiration/expiration; tell patient to breathe slowly, deeply
through mouth; auscultate posterior chest (head bent forward, arms crossed), lateral chest - raise
arms, anterior chest - erect w/ shoulders back
Auscultation (All Patients Easily Take Medicine) Aortic, Pulmonic, Erb's Point, Tricuspid,
Mitral
Baby otoscopic examination use supine or prone position, turn head to side, pull auricle down to
straighten auditory canal; tympanic membrane is usually extremely oblique, light reflex may
appear diffuse.
Bell of stethoscope best for low-pitched sounds
Bimanual digital palpation one palm under right breast, walk fingers of other hand across
tissue, feeling for lumps while compressing tissue
Bimanual liver palpation use for obese individuals
Biot respiration irregular breathing, varies in depth, interrupted irregularly w/ apneic
intervals
Blumberg Rebound tenderness - peritoneal irritation, appendicitis
Borborygmi loud prolonged gurgles (stomach growling)
Bradycardia under 60 bpm, can indicate probs with electrical system
, Bradypnea def slow breathing (metabolic alkalosis, central nervous system lesions (cerebrum),
myasthenia gravis, narcotic overdoses, extreme obesity)
Bradypnea rate slower than 12 breaths/min.
Braun von Fernwald Fullness and softening of fundus site of implantation 7- 8 weeks
Breast contour should be uninterrupted
Breast lesions note new ones or recent changes
Breast mass characterize and palpate dimensions, consistency, and mobility. Eval for fluid w/
U/S
Breast skin color/texture should appear smooth. Look for retractions, dimpling, and a peau
d'orange (or orange-peel) appearance.
Breath sounds listen for intensity, pitch, quality, and inspiratory and expiratory duration. Expect
to hear normal breath sounds.
Breech presentation FHR is heard above umbilicus.
Bronchial sounds highest in pitch and intensity and only normal over the trachea.
Bronchophony test pt. says "99", auscultate posterior chest; normal = muffled and indistinct,
clearer/louder = positive
Bronchovesicular moderate pitch/intensity, heard over the major bronchi
Bruit may reflect blood flow turbulence, indicate vascular disease
Cancer usually unilateral, single, irregular/stellate, hard/stonelike, fixed, retraction common,
usually nontender, irregular borders, does not vary w/ menses
Carotid artery pulse Palpate as you feel precordium; carotid pulse and S1 should be nearly
simultaneous
Cataract risk factors family history, steroids, UV exposure, cigarette smoking, DM, aging
Chadwick Bluish color of the cervix, vagina, and vulva 8- 12 weeks
Chest and lung palpation expected findings bilateral symmetry, some rib cage elasticity, relative
inflexibility of the sternum and xiphoid, and a rigid thoracic spine.
Chest and lung palpation unexpected findings crepitus (a crackly or crinkly sensation) and
pleural friction rub (a palpable, grating vibration).
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