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HAP > 4. Assessment Techniques; General Survey; Vital Signs; Pain > Flashcards

4. Assessment Techniques; General Survey; Vital Signs; Pain Flashcards

1
Q

what is the order of assessment?

A
  • inspection
  • palpation
  • percussion
  • auscultation
  • *not for abdominal assessment**
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2
Q

what are some characteristics/qualities that can be assessed via palpation?

A
  • texture
  • temperature
  • moisture
  • organ location/size
  • swelling
  • vibration/pulsation
  • crepitation
  • abnormal lumps/masses
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3
Q

fingers and thumbs are used to ______ during an assessment?

A

grasp

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4
Q

back of the hand is called?

A

dorsa

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5
Q

what kinds of information can percussion provide?

A
  • Mapping out location and size of an organ
  • Signaling density of a structure (air, fluid, solid)
  • Detecting abnormal masses
  • Detecting tenderness
  • Eliciting deep tendon reflexes (percussion hammer)
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6
Q

what are you listening for when performing indirect percussion?

A
  • amplitude
  • pitch
  • quality
  • duration
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7
Q

define auscultation

A

to listen to body sounds

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8
Q

what is the general survey?

A
  • aids in the formation of global impression of the person

- includes physical appearance, body structure, mobility, and behavior

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9
Q

physical appearance: overall appearance

normal: ?
abnormal: ?

A

Normal: appears stated age, facial features, movements and body are symmetrical

Abnormal: appears older than stated age

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10
Q

physical appearance: hygiene, dress

normal: ?
abnormal: ?

A

Normal: well-groomed; clean clothing

Abnormal: appears disheveled, malodorous, ill-fitting clothes

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11
Q

physical appearance: sexual development

normal: ?
abnormal: ?

A

Normal: appropriate for age and gender

Abnormal: delayed or early puberty

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12
Q

physical appearance: skin color

normal: ?
abnormal: ?

A

Normal: even tone, normal for ethnicity, no lesions

Abnormal: discoloration (pallor, cyanosis, jaundice, etc.) or lesions

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13
Q

physical appearance: facial features

normal: ?
abnormal: ?

A

Normal: symmetric, no distress

Abnormal: drooping, grimacing, mask-like

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14
Q

body structure: stature

normal: ?
abnormal: ?

A

Normal: height in normal range for age, gender, genetic heritage

Abnormal: gigantism, dwarfism

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15
Q

body structure: nutrition

normal: ?
abnormal: ?

A

Normal: weight in normal range for height and build, even body fat distribution

Abnormal: cachexia, anorexia nervosa, cushing syndrome, obesity

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16
Q

body structure: symmetry

normal: ?
abnormal: ?

A

Normal: equal bilaterally, relative proportion

Abnormal: atrophy, hypertrophy

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17
Q

body structure: posture

normal: ?
abnormal: ?

A

Normal: erect

Abnormal: lordosis, kyphosis, scoliosis, slumped

18
Q

body structure: position

normal: ?
abnormal: ?

A

Normal: comfortable, relaxed

Abnormal: tripod position, fetal position

19
Q

body structure: body build

normal: ?
abnormal: ?

A

Normal: arm span equal to height and crown to pubis equal to pubis to sole, no obvious deformities

Abnormal: Marfan syndrome, missing extremities or digits, shortened limbs, webbed digits

20
Q

mobility: gait
normal: ?
abnormal: ?

A

Normal: shoulder-width base, proper arm swing, smooth/even/balanced

Abnormal: wide base, shuffling, dragging, limping

21
Q

mobility: ROM
normal: ?
abnormal: ?

A

Normal: smooth and coordinated, no involuntary movements

Abnormal: limited, stiff, uncoordinated, jerky, paralysis, tics, tremors

22
Q

emotional/mental status: behavior

normal: ?
abnormal: ?

A

Abnormal: agitation, confusion, lethargy

23
Q

what are the assessment techniques for vital signs?

A

inspection, palpation, and auscultation

24
Q

what are considered vital signs?

A
  • temperature
  • pulse
  • respirations
  • blood pressure
  • O2 saturation
  • pain
25
Q

what are some important measurements to take during the assessment?

A

height, weight, BMI, waist circumference,

26
Q

what is the normal oral temperature range?

A
  1. 8 C - 37.3 C

96. 4 F - 99.1 F

27
Q

what is the normal rectal temperature?

A

0.5 C (1 F) higher than oral temp

28
Q

what is normal axillary temperature?

A

0.5 C (1 F) lower than oral temp

29
Q

what assessment technique is used to take someone’s pulse?

A

palpation of the radial pulse

30
Q

pulse:
what is normal rate?
how long do you count?

A

60 - 100 bpm

  • regular: count for 30 seconds
  • irregular: count for 1 min.
31
Q

respirations:
what is normal rate?
how long do you count?

A

12 - 20 respirations/min

  • regular: count for 30 seconds and * 2
  • irregular: count for 1 min
32
Q

what is systolic BP?

A

maximum pressure during left ventricular contraction; or systole

33
Q

what is diastolic BP?

A

resting pressure or pressure that blood exerts constantly between each contraction; diastole

34
Q

what is normal BP?

A

<120/80 mmHg

sky/dirt ->working heart/resting heart

35
Q

what is proper positioning when measuring BP?

A
  • arm at heart level

- legs uncrossed

36
Q

blood pressure varies on…

A

age, weight, exercise, emotions, stress, etc.

37
Q

what is a korotkoff sound?

A

what you are listening for with the stethoscope while doing blood pressure

38
Q

phase 1 of BP measurement:

key points

A
  • first sound heard is the systolic blood pressure
39
Q

phase 2 of BP measurement:

key points

A
  • soft swooshing sound due to turbulent blood flow through partially occluded artery
  • the sound heard throughout the majority of time between systolic and diastolic pressures
40
Q

phase 3 of BP measurement:

key points

A
  • crisp, high-pitch knocking sound

- may occur as brachial artery opens more but still closes shortly before diastole

41
Q

phase 4 of BP measurement:

key points

A
  • abrupt muffling of sound

- typically occurs ~10mm Hg above diastolic BP

42
Q

phase 5 of BP measurement:

key points

A
  • last audible sound is the diastolic BP

HAP (2 decks)

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