Pointers HA

PRELIMS
Collecting Objective Data Tympany (heard over air)
Inspection – involves using the senses Intensity: Loud
of vision, smell, and hearing to Pitch: High
observe and detect any normal or Length: Moderate
abnormal findings. Quality: Drumlike
Palpation – consists of using parts of Example of Origin: Puffed-out
the hand (fingerpads, ulnar/palmar cheek, gastric bubble
surface, and dorsal surface) to touch Dullness (heard over more solid
and feel. tissue)
Types of Palpation: Intensity: Medium
Light Palpation – Used to feel pulses, Pitch: Medium
tenderness, surface skin texture, Length: Moderate
temperature, and moisture. Quality: Thud-like
Moderate Palpation – Depress the skin Example of Origin: Diaphragm,
surface 1 to 2 cm. Used feel easily pleural effusion, liver
palpable body organs and masses. Flatness (heard over very dense
Deep Palpation – Surface depression tissue)
should be 2.5 to 5 cm. Used to feel Intensity: Soft
very deep organs or structure that are Pitch: High
covered by thick muscles. Length: Short
Bimanual Palpation – Use two hands, Quality: Flat
placing one on each side of the body Example of Origin: Muscle, bone,
part being palpated. Use one hand to sternum, thigh
apply pressure and the other hand to Auscultation – type if assessment
feel the structure. technique that require the use of
Percussion – involves tapping body stethoscope.
parts to produce sound waves. Diaphragm – used to listen for high
Types of Percussion: pitched sounds like normal heart
Direct – direct tapping of a body part sounds, breath sounds, and bowel
with one or two fingertips to elicit sounds.
possible tenderness. Bell – used to listen to low pitched
Blunt – used to detect tenderness over sounds like abnormal heart sounds and
organs. bruits.
Indirect – most commonly used method Glasgow Coma Scale (GCS)
of percussion. Produces a sound or Eye Opening Response
tone that varies with the density of Spontaneous Opening 4
underlying structures. To Verbal Command 3
Sounds Elicited by Percussion: To Pain 2
Resonance (heard over part air and No Response 1
part solid) Most Appropriate Verbal Response
Intensity: Loud Oriented 5
Pitch: Low Confused 4
Length: Long Inappropriate Words 3
Quality: Hollow Incoherent 2
Example of Origin: Normal Lung No Response 1
Hyperresonance (heard over mostly air) Most Integral Motor Response (Arm)
Intensity: Very Loud Obeys Verbal Commands 6
Pitch: Low Localized Pain 5
Length: Long Withdraws from pain 4
Quality: Booming Flexion (decorticate
Example of Origin: Lung with rigidity) 3
Emphysema Extension (decerebrate

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 rigidity) 2 Pulse rate deficit is the discrepancy
No Response 1 between the apical and radial pulse.
Total Score 3-15
SEMIFINALS
Increased anteroposterior chest
diameter can cause difficulty in
palpating apical impulse of older
clients.
Atherosclerosis may cause obstruction
and compression may easily block
circulation in older clients.
Occlusion of the Carotid Arteries at
the same time may result to reduced
cerebral blood flow
Pulse Amplitude Scale
0 = Absent
1+ = Weak, diminished (easy to
obliterate)
2+ = Normal (obliterate with
normal pressure)
3+ = Strong (unable to
obliterate or requires firm pressure)
4+ = Bounding (unable to
obliterate)
When evaluating Jugular Venous
Pressure, distension, bulging or
protrusion at different positions may
provide the nurse with significant
information.
Fatigue may result from compromised
Cardiac Output. Fatigue related to
decreased CO is worse in the evening
or as the day progresses, whereas
fatigue seen with depression is
ongoing throughout the day.
Dyslipidemia presents the greatest
risk for developing coronary artery
disease. Elevated cholesterol levels
have been linked to the development of
atherosclerosis.
Smoking is a predisposing factor to
heart disease.
Orthopnea (difficulty in breathing
when lying supine) may be associated
with cardiovascular problem.
Areas of Auscultation
A – Aortic (Right 2nd ICS, MSB)
P – Pulmonic (Left 2nd ICS, MSB)
E – Erb’s (Left 3rd ICS, MSB)
T – Tricuspid (Left 4th ICS, MSB)
M – Mitral (Left 5th ICS, MCL)
𝑺𝟐 sound can be heard using the
diaphragm at the base of the heart.
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Auscultation is the most often
assessment technique used when
evaluating the cardiovascular system.
Thrill is the palpable murmur
described as feeling like the throat
of a purring cat.
Diaphragm is used in auscultating
normal heart sounds.
Allen’s Test evaluates the patency of
radial and ulnar arteries.
FINALS
Rotator Cuff Tear – manifested by
painful and limited abduction
accompanied by muscle weakness and
atrophy.
Dislocation – manifested by flat,
hollow, or less-rounded shoulders.
Herniated Lumbar Disc or Ankylosing
Spondylitis – manifested by a
flattened lumbar curvature.
Lasegue Test – a test for Leg Pain,
done by raising the client’s leg to
the point of pain while lying flat on
bed. Shooting pain when lowering or
raising the leg below the knee suggest
Herniated Intervertebral Disc.
Lordosis – exaggerated lumbar curve;
often seen in pregnancy and obesity
Scoliosis – lateral curvature of the
spine with an increase in convexity on
the side that is curved.
Kyphosis – rounded thoracic cavity.
TMJ Disfunction – manifested by a
clicking, popping, or grating sound.
Muscle Strength Rating
Rating Explanation Strength
Classification
Active Motion
5 against full Normal
resistance
Active Motion
4 against some Slight
resistance Weakness
Active Motion Average
3 against gravity Weakness
Passive ROM
(gravity removed Severe
2 and assisted by Weakness
examiner)
No
0 Muscular Paralysis
 Contraction
Rickets – (Vitamin D Deficiency) is
associated with Osteomalacia.
Vitamin C – promotes tissue healing
Osteoporosis – risk factors (late
menarche/early menopause) reduces risk
by moderate to intense exercise which
promotes bone density.
Having diabetes mellitus, sickle cell
anemia, or Systemic Lupus
Erythematosus places the risk of
developing musculoskeletal problems.
Type 1 diabetes increases risk of low
bone density, and may increase
fracture risk, but fractures may be
related to poor vision and nerve
damage, which are likely to produce
falls.
Type 2 diabetes often have increased
body weight and there by increased
bone density, they too are likely to
have an increased risk of fractures
due to vision and nerve damage.
Weight gain can increase physical
stress and strain on the
musculoskeletal system.
Clients with Temporomandibular joint
(TMJ) dysfunction may have difficulty
in chewing and may describe their jaws
as “getting locked or stuck.”
Some Medications can affect
musculoskeletal function. Diuretics
can alter electrolyte levels, leading
to muscle weakness. Steroids can
deplete bone mass, thereby
contributing to osteoporosis. Adverse
reactions to HMG-CoA reductase
inhibitors (statins) can include
myopathy, which can cause muscle pain,
soreness, tiredness, or weakness.
Test for Stereognosis – place a
familiar object such as coin, key,
etc. in the client’s hand and ask the
client to identify.
Test for Graphesthesia – use a blunt
instrument to write a number, such as
2,3, or 5 on the palm of client’s
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hand. Ask the client to identify the
number.
Test sensitivity to position –
performed by moving the client’s toe
finger/thumb up and down.
Test for Coordination – performed
touching the nose using the right and
left finger simultenously.
Test for Gag Reflex – touch the
posterior pharynx using a tongue
depressor.
Brudzinski Sign - performed by flexing
the client’s neck while lysing supine.
Kernig Sign – performed by flexing the
client’s knee then straightening it
while lying supine.
Positive Romberg Test – swaying and
moving feet apart to prevent fall is
seen with disease of the posterior
columns, vestibular dysfunction, or
cerebellar disorder.
Fasciculation – continuous, rapid
twitching of resting muscles.
Tremors – involuntary contraction of
opposing groups of muscles.
Tics – involuntary repetitive
twitching movements.
Myoclonus – sudden jerks of arms or
legs
Chorea – sudden rapid, jerky voluntary
and involuntary movements of limbs,
trunk, or face.
Athetosis – twisting, writhing, slow
continuous movements
Abnormal Gaits
Cerebellar Ataxia – wide-based,
staggering, unsteady gait
Parkinsonian Gait – shuffling gait,
accomplished in very stiff manner.
Stooped-over posture with flexed hips
and knees.
Scissors Gait – Stiff, short gait;
thighs overlap each other with each
step.
Spastic Hemiparesis – flexed arm held
close to body while client drags toe
of leg or circles it stiffly outward
and forward.
Foodtdrop – Lifts foot and knee high
with each step, then slaps the foot
down hard on the ground; cannot walk
on heels