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Physical Assessment


Physical Assessment
  
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Erythema
 
Redness of the skin.
Cyanosis
 
Bluish coloring of the skin and mucous membranes.
Jaundice
 
Yellow appearance of skin.
Pallor
 
Paleness of the skin.
Ecchymosis
 
Collection of blood in subcutaneous tissues that causes a purplish discoloration.
Petechiae
 
Small, purplish hemmorragic spots on the skin that do not blanch with applies pressure
Lesion
 
Any abnormal tissue on the skin.
Wound
 
Injury that results in a disruption in the normal continuity of the body tissue.
Rash
 
A change of the skin which affects its color, appearance or texture.
Diaphoresis
 
Excessive sweating commonly associated with shock or other medical conditions.
Turgor
 
Tension of the skin determined by its hydration.
Edema
 
Accumulation of fluid in extracellular spaces.
Pitting Edema
 
Edema in which fluid builds up in the extremeties to such a degree that when the fluid filled extremity is gently pushed with a finger, a depression will remain in the flesh for some time before the flesh slowly bounces back into place.
Beau's Lines
 
Deep grooved lines that run from side to side on the fingernail.
Paronychia
 
A nail disease in which often tender bacterial or fungi hand infection where the nail and skin meet at the side or base of the nail.
Clubbing
 
Rounding and swelling of nail beds.
Alopecia
 
Baldness.
Hirsutism
 
Excessive hairiness.
Periorbital edema
 
"puffy" or swelling around the eyes.
Mydriasis
 
Dilation of pupil due to disease, use of drugs or trauma.
Miosis
 
Constriction of pupil of the eye resulting from normal response to an increase in light or caused by certain drugs or pathological conditions.
Accommodation
 
Ability to adjust the eye to see at various distances.
Convergence
 
Following an object as it nears your face. Becoming cross-eyed in the process.
Ptosis
 
Drooping of upper or lower eyelid.
Entropion
 
Medical condition in which the eyelid (usually lower one) folds inward.
Ectropion
 
Condition where lower eyelid folds outwards.
Nares
 
Nostril or nasal passages./
Lymphadenopathy
 
Term meaning disease of the lymph nodes.
Barrel Chest
 
A increase in the anterior posterior diameter of the chest wall resembling the shape of a barrel, most often associated with emphysema.
Fremitus
 
Vibration of the chest wall that can be palpated during physical assessment.
Resonance
 
Heard during percussing a patient.
Tympany
 
Heard when percussing a patient. Hollow sounding.
Stertorous Breathing
 
Loud breathing.
Stridor
 
Harsh, high-pitched sound usually heard in inspiration when upper airways become narrowed.
Bruit
 
Unusual sound, usually abnormal, heard in auscultation.
Phlebitis
 
Inflammation of a vein.
Striae
 
Irregular areas of skin that look like bands, stripes or lines.
Atrophy
 
Decrease in size of body structure.
Crepitus (crepitation)
 
Grating, crackling or popping sounds and sensations experienced under the skin and joints.
Aphasia
 
Acquired language disorder in which there is an impairment of language use.
Hygiene/ Grooming
 
clean, disheveled, clothes dirty, clothes inappropriate for the season, dressed for occasion, hygiene/grooming performed by staff, unkempt
Body Build
 
small, medium, or large frame, flabby, firm, malnourished, obese
Affect
 
appropriate, flat, inappropriate, labile, blunted, paranoid, euphoric
Mood
 
happy, sad, anxious, frustrated, tense, cooperative, restless, contented, angry, indifferent, detached
Skin Color
 
tanned, vitiligo, freckled, erythema, ecchymosis, increased pigmentation
Lesions/ Abnormalities
 
striae, moles, birthmarks, petechiae, blister, nodule, pustule, cyst, ulcer, scale, keloid, cherry angioma, spider angioma, hematoma, senile keratosis, fissure, abrasion, scratch, skin tear, scar, lentigo senilis (age spots), senile purpura (vivid purple patches), skin tags
Nail Texture
 
Smooth, ridged
Nail Color
 
pink, cyanotic, yellowed
Hair Distribution
 
full, thin, even, patchy, receding hairline, male pattern baldness
Head Size
 
small, average, large
Head Shape
 
round, oval, square, pointed, asymmetrical
Eye Placement
 
normal, high, low, aysmmetrical
Sclera Color
 
white, red, yellow, dirty white related to aging
Vision
 
VISION: normal with glasses, holds items close to face to see, unable to reach newspaper, unable to see objects at a distance, describe what you observe about the patient’s ability to see both far and near objects
S1 and S2
 
clear, crisp, muffled, soft, unable to distinguish the two sounds, swish, click, loud
Vein Patterns
 
visible, non-visible, varicosities (identify where), prominent
Chest Movement
 
symmetrical, asymmetrical
ROM
 
full, MAE equally, jerky movements, uncoordinated, slow, limited with pain, weak, strong
Gait
 
Shuffling, propulsive, limping, pigeon toed, slapping, toes point outward (duck walk), smooth, coordinated, drags one leg, unable to walk, scissor, ataxia
Balance
 
Steady, erect, leans to side (identify the side), sits erect in wheelchair, leans forward, leans backward

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