assessment techniques Flashcards
standard equipment for vital signs
platform scale, stethoscope, sphygmomanometer, thermometer
washing in/out
washing in - protects patient from the nurse
washing out - protects nurse from the patient
goals for patient positioning
- provide patient comfort and safety
- maintain patient dignity and privacy
- allows maximum visibility and access
essentially comfort, safety, privacy
supine position
face up position
fowler’s
sitting up, 30-45 degree angle
orthopenic position
AKA tripod position, laying over, helps with shortness of breath
prone position
helps oxygenate, face down
lateral position
side lying
lithotomy position
mainly for surgical or obstetric procedures, “childbirth” position
trendelenburg position
head down and feet up (or vice versa)
other equipment for physical examination
patient specific
- otoscope, ophthalmoscope, penlight, pocket vision screener
types of precautions for PPE (what are you protecting yourself from)
airborne, droplet, contact, contact and enteric, neutropenic precautions/protective isolation
airborne precautions
- most contagious
- airborne droplets stay in air for up to 2 hours
- measles, chicken pox, herpes, TB
- needs N95 mask/particulate respirator, gown, gloves, goggles
droplet precautions
private room, large drops that go out about 3 feet and fall to floor
- PPE: surgical mask within 3 feet of client, wear gown, goggles, and gloves
contact and enteric precautions
private room, diseases with diarrhea, wash hands with soap and water; alcohol does NOT kill these diseases so you have to wash
neutropenic precautions
gloves for all procedures, for the immunosuppressed
- no live vaccines, avoid invasive procedures, no live flowers
- no white cell count, immunocompromised
donning
- putting on
- ON: gown, mask, goggles, gloves
doffing
- taking off
- alphabetical order
- OFF: gloves, goggles, gown, mask
standard precautions
- hand hygiene
- wearing appropriate PPE
- how to handle patient equipment
- injection safety practices
- environmental cleaning
- respiratory hygiene/coughing etiquette
assessment techniques
inspection, palpation, percussion, auscultation
sequence of health assessment
- maximize client’s comfort
- avoid unnecessary changes in position
- enhance clinical efficiency
inspection
- close, careful scrutiny
- begins with general survey
- inspection always comes first
- requires good lighting, adequate exposure, occasional use of instruments like otoscope, ophthalmoscope, penlight, nasal and vaginal specula
palpation
assesses
- texture, temperature, moisture
- organ location and size
- swelling, vibration, pulsation, or crepitation
- rigidity or spasticity
- presence of lumps or masses
- presence of tenderness or pain
bimanual palpation
used only for certain body parts or organs; doctor or provider will do this
fingertips (palpation)
best for fine tactile discrimination of skin texture, swelling, pulsation, presence of lumps
fingers and thumbs
detection of position, shape, and consistency of an organ or mass
dorsa of hands and fingers
best for determining temperature because skin is thinner than on palms
base of fingers or ulnar surface of hand
best for vibration
percussion
tapping person’s skin with short, sharp strokes to assess underlying structure (bone, air, etc)
amplitude (intensity)
loud or soft sound
pitch
frequency, number of vibrations per second
basic principles of percussion
structure with more air produces louder, deeper sound compared with denser structure
diaphragm of stethescope
high pitched sounds
bell of stethescope
low pitched sounds
ear tips
aim anteriorly, ears toward your patient
auscultation
listening to sounds made by arteries, heart, lungs, bowel sounds
bruit
swooshing sound in artery
murmur
swooshing sound in a heart valve
frequency of assessments
depends on patient needs, hospital protocol, purpose of data collection, health care setting, facility standard of care
