Nursing Faculty
Philadelphia University
Critical Care Nursing (Clinical)
Physical Assessment Terminology
Stridor
Tripod position
Sigh
Tachypnea
Bradypnea
Hyperventilation
Kussmaul's breathing
Hypoventilation
Cheyne-stokes
respiration
Biot's breathing
Chronic obstructive
breathing
Orthostatic
hypotension
High-pitched, monophonic, inspiratory, crowing
sound, louder in neck than over chest wall
Leaning forward with arms braced against the knees,
chair, or bed. limited mobility
Deep breathing
Rapid shallow breathing. Increased rate more than 24
per minute
Slow breathing. A decreased but regular rate less than
10 per minute.
Increase in both rate and depth
Air hunger (as in hyperventilation)
An irregular shallow pattern
A cycle in which respirations gradually wax and wane
in a regular pattern, increasing in rate and depth and
then decreasing. The breathing periods last 30 to 45
seconds, with periods of apnea (20 seconds)
alternating the cycle.
Similar to cheyne- stokes respiration ,except that the
pattern is irregular . a series of normal respirations(3
or 4) is followed by a period of apnea. The cycle
length is variable, lasting anywhere from 10 seconds
to 1 minute
Normal inspiration and prolonged expiration
A drop in systolic pressure of more than 20 mmhg,
and or orthostatic pulse increases of 20 beats per
minute or more ,occurs with a quick change to a
standing position
● Head:Microcephaly
Macrocephaly
Crepitation
Abnormally small head
Abnormally large head
An audible and palpable crunching or grating that
accompanies movement
Course coordinator: Dr. abdul-Monim Batiha
1
Nursing Faculty
Philadelphia University
● Eye:Presbyopia
Strabismus
Nystigmus
Ptosis
Periorbital edema
Raccoon eye
Exophthalmos
Enophthalmos
Scleral icterus
The decrease in power of accommodation with aging
(person move paper farther away )
Deviated gaze or limited eye movement
A fine oscillating movement best seen around the iris
Dropping of upper eyelid
Edema around the eyes
Lids are swollen & puffy
Echymosis around the eye
Protruding eyes
Is a forward displacement of the eyeballs and widened
palpebral fissures
Sunken eyes
An even yellowing of the sclera extending up to the
cornea ,indicating jundice
● Nose:Rhinorrhea
Epistaxis
● Mouth:-
Leakage of cerebrospinal fluids (CSF)from nose
Nasal bleeding
Cheilitis
Gingival hypertrophy
Gingivitis
Bifid uvula
Aphasia
Cracking at the corners
Cervices between teeth and gums, pockets of debris
Gum bleeds easily
It looks like it is split in two
Loss of ability to speak or write coherently or to
understand speech or writing
● Ear:Microtia
Macrotia
Battle's sign
Atresia
Otorrhea
Ears smaller than 4cm vertically
Ears larger than 10 cm vertically
Ecchymosis behind ear
Absence or closure of the ear canal
Leakage of cerebrospinal fluids (CSF) from ear
● Neck:Lymphadenopathy
Enlargement of the lymph nodes ( > 1 cm )
Course coordinator: Dr. abdul-Monim Batiha
2
Nursing Faculty
Tracheal shift
Tracheal tug
Bruit
Carotid sinus
hypersensitivity
Diminished pulse
Increased pulse
Bruit
Elevated jugular
venous pressure
● Chest:Barrel chest
Scoliosis
Kyphosis
Pectus excavatum
Pectus carinatum
Rhonchal fremitus
Pleural friction
fremitus
Pleural friction rub
Philadelphia University
Trachea is deviated to one side
A rhythmic downward pull that is synchronus with
systole
A soft ,pulsatile, whooshing, blowing sound heard
best with the bell of the stethoscope
The condition in which pressure over the carotid sinus
leads to a decreased heart rate ,decreased blood
pressure ,and cerebral ischemia and syncope
Pulse feels small and weak
Pulse feels full and strong
Blowing ,swishing sound auscultated over artery with
bell
A level of pulsation is more than 3 cm above the
sternal angle while at 45 degrees
Equal; anteroposterior – to- transverse diameter and
that the ribs are horizontal instead of the normal
downward slop & costal angle more than 90 degrees
A lateral S – shaped curvature of the thoracic and
lumbar spine, usually with involved vertebrae
rotation.
An exaggerated posterior curvature of the thoracic
spine (humpback) that causes significant back pain
A markedly sunken sternum and adjacent cartilages
(also called funnel breast) depression begins at second
intercostals space ,becoming depressed most at
junction of xiphoid with body of sternum .more
noticeable on inspiration
A forward protrusion of the sternum,with ribs sloping
back at either side and vertical depressions along
costochondral junction (also called pigeon breast)
Vibration felt when inhaled air passes through thick
secretions in the larger bronchi
A palpable coarse grating sound sensation with
breathing
A very superficial sound that is coarse and low
Course coordinator: Dr. abdul-Monim Batiha
3
Nursing Faculty
Crepitation, Rales
● Precordium:Heave or lift
Thrill
Premature beat
Irregularly irregular
Pulse deficit
Murmur
Pericardial friction rub
Philadelphia University
pitched ,it has a grating quality as if two pieces of
leather are being rubbed together, sounds just like
crackles, but close to the ear, sounds louder if you
push the stethoscope harder onto the chest wall, sound
is inspiratory and expiratory
An unusual soft crackling sound heard in the lungs
through a stethoscope. Also called rale
A sustained forceful thrusting of the ventricle during
systole
It is a palpable vibration .It feels like the throat of a
purring cat
An isolated beat is early, or a pattern occurs in which
every third or forth beat sounds early
No pattern to the sounds, beats come rapidly and at
random intervals
Apical pulse is more than radial pulse
A blowing, swooshing sound auscultated over heart or
great vessels
High pitched and scratchy sound, like sandpaper
being rubbed it is best heard with the diaphragm with
the person sitting up and leaning forward and with the
breath held in expiration
● Abdomen:Scaphoid
Protuberant
Hernia
Inverted umbilicus
Everted umbilicus
Striae
Hyperactive bowel
sounds
Sunken
Protruded
Protrusion of abdominal viscera through abdominal
opening in muscle wall
Deeply sunken
Pushed upward and enlarged
Common pigment change ,silvery white, linear,
jagged marks about 1-6 cm long
Recent striae are pink or blue then they turn slivery
white
Loud ,gurgling sounds high –pitched ,rushing,
tinkling sounds
Course coordinator: Dr. abdul-Monim Batiha
4
Nursing Faculty
Philadelphia University
Hypoactive bowel
sounds
Absent bowel sound
● Extremities:-
Diminished or absent bowel sounds
Positive Homan's sign
Dislocation
Subluxation
Ankylosis
Crepitation
Calf pain when dorsiflex the foot toward the tibia
One or more bones in a joint being out of position
Partial dislocation of a joint
Stiffness or fixation of a joint
An audible and palpable crunching or grating that
accompanies movement
Hard to palpate ,need to search for it ,may fade in and
out, easily obliterated by pressure
Easily palpable, pounds under the fingertips
Greater than normal force ,then collapses suddenly
Weak thready pulse
Full, bounding pulse
Water-hammer
(corrigan's)pulse
Pulsus bigeminus
Pulsus alternans
Pulsus paradoxus
Pulsus bisferiens
Clubbing nails
Muscle atrophy
Muscle hypertrophy
Contracture
Paresis
Plegia
Flaccidity
Spasticity
Absent for 5 minutes
Rhythm is coupled, every other beat comes early ,or
normal beat followed by premature beat .force of
premature beat is decreased
Rhythm is regular ,but force varies with alternating
beats of large and small amplitude
Beats have weaker amplitude with inspiration,
stronger with expiration. Best determined during
blood pressure measurement, reading decreases more
than 10 mm Hg during inspiration and increase with
expiration
Each pulse has two strong systolic peaks ,with a dip in
between beat assessed at the carotid artery
Diffuse enlargement of terminal phalanges
Abnormally small muscle with a wasted appearance
Increased size and strenghth of muscle
Shortening of a muscle
Weakness or diminished strength
Paralysis or absence of strength
Decrease or loss of motor power
Decreased resistance hypotonic
Rigidity increased resistance
Course coordinator: Dr. abdul-Monim Batiha
5
Nursing Faculty
Tic
Tremor
Chorea
Athetosis
Hypalgesia
Analgesia
Hyperalgesia
Hypoesthesia
Anesthesia
Hyperesthesia
Parasthesia
Clonus
Hyperreflexia
Hyporeflexia
● Nutritional status:Percent ideal body
weight
Mild malnutrition
Moderate malnutrition
Severe malnutrition
Obesity
Philadelphia University
Repetitive twitching of a muscle group at
inappropriate times example wink, grimace ,head
movement ,shoulder shrug
Involuntary contraction of opposing muscle groups
results in rhythmic ,back and forth movement of one
or more joints may occur at rest or with voluntary
movement disappear while sleeping
Sudden ,rapid, jerky, purposless movement involving
limbs, trunk, or face occurs at irregular intervals ,not
rhythmic or repetitive, more convulsive than a tic.
Some are spontaneous ,and some are initiated, all are
accentuated by voluntary acts. Disappears with sleep
Slow, twisting, writhing, continuous movement,
resembling a snake or worm. Involves distal part of
limb more than the proximal part
Disappears with sleep. Athetoid hand –some fingers
are flexed and some are extended
Decreased pain sensation
Absent pain sensation
Increased pain sensation
Decreased touch sensation
Absent touch sensation
Increased touch sensation
Abnormal sensation
Repeated reflex muscular movement
A set of short jerking contractions of the same muscle
Exaggerated reflex
Decreased reflex
= 80-90%
= 70-80%
= Less than 70%
= More than 120%
Course coordinator: Dr. abdul-Monim Batiha
6
Nursing Faculty
Philadelphia University
Body mass index
Underweight
Normal weight
Overweight
Obesity
Extreme obesity
● Mental Status:-
BMI = less than 18.5
BMI = 18.5-24.9
BMI = 25.0-29.9
BMI = 30.0-39.9
BMI = More than 40
Recent amnesia
Remote amnesia
Delusions
Recent memory deficit in the last 24 hours
Memory loss of verifiable past events
Firm, fixed, false beliefs, irrational, person sticks to
delusion despite objective evidence to contrary
Sensory perceptions for which there are no external
stimuli ,may strike any sense: visual, auditory, tactile,
olfactory, gustatory
Misperception of an actual existing stimulus ,by any
sense
Hallucination
Illusion
Course coordinator: Dr. abdul-Monim Batiha
7