Assessing Health Status_22 Flashcards
Adventitious sounds
abnormal lung sounds
Auscultation
process of listening with the aid of the stethoscope to sounds produced in the body
Bronchovesicular sounds
heard over the central chest or the back
Dual-energy x-ray absorptiometry (DXA)
Bone density—screening for osteoporosis with a dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine for women aged 65 years and older.
Edema
fluid in the tissues
lordosis
exaggerated lumbar curve
kyphosis
increased curve in the thoracic area
scoliosis
pronounced lateral curvature of the spine
nystagmus
a vision condition in which the eyes make repetitive, uncontrolled movements. These movements often result in reduced vision and depth perception and can affect balance and coordination. These involuntary eye movements can occur from side to side, up and down, or in a circular pattern.
Olfaction
is the sense of smell. The nose is used to identify characteristic smells associated with specific problems. A fruity odor to the breath can indicate diabetic acidosis; alcohol on the breath can provide a clue to the patient’s lethargy or irrationality. Foul mouth odor may indicate periodontal disease or poor oral hygiene. A foul or sweet odor coming from under a cast or a wound indicates infection. A foul odor in the female genital area may indicate a vaginal infection.
Palpation
involves using the hands to feel various parts of the body. Palpation can be used to detect the size, shape, and position of parts of the body and the texture, temperature, and moisture of the skin. Palpation is used to ascertain:
- Muscle spasm or rigidity
- Pain, swelling, or a growth
- Any restriction in movement of a body part
- Skin temperature, turgor (elasticity), and edema (fluid in the tissues)
Percussion
Percussion supplies other information about structures of the body. It involves light, quick tapping on the body surface to produce sounds. Variations in the sounds reflect the characteristics of the organs or structures below the surface. Percussion is used primarily over the chest and abdomen to determine the size, location, and density of organs that lie within. The most common type of percussion consists of striking the middle finger of one hand with the index or middle finger of the other hand. When tapping, do not move the forearm; all the force is generated by a quick snap of the wrist. The tapping finger makes a quick contact with the other hand, and after two or three taps in one location, the hands are moved to another area.
Quadrants of the Abdomen
Assess bowel sounds on admission and once per shift for all patients. Bowel sounds are produced by the contractions of the small and large intestine. They are wavelike clicks and gurgles that occur from 5 to 30 times a minute. They are particularly active after eating; between meals, it is normal to hear only a few sounds. Bowel sounds are 387described as hyperactive if they are very frequent, hypoactive if there are long periods of silence, and absent if no sound is heard for 2 to 5 minutes in any of the four quadrants. With the patient in a supine position, lightly place the stethoscope over a quadrant (quarter) of the abdomen and listen; if no sound is heard, progress through the other quadrants until sounds are heard or listen for at least 2 minutes
Detecting Tremors
The pads of the fingers are used to palpate the size, position, and consistency of various structures, such as the lymph nodes and breast tissue. The palm of the hand is used to detect vibrations or tremors (involuntary fine movement of the body or limbs), and the thumb and index finger are used to check skin turgor, joint position, and the firmness of muscles and other tissues.
Skin Turgor
Elasticity of the skin
