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Nurse Assessment > Assessment Techniques and Safety in The Clinical Setting > Flashcards

Assessment Techniques and Safety in The Clinical Setting Flashcards

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1
Q

What is the first step in the assessment process?

A

IPPA

Inspection. Careful, thorough observation

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2
Q

What do you do during Inspection?

A

Symmetry
Compare the patient’s right with the left side.

Look for similarities/differences

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3
Q

Should you use dark or good lighting during inspection?

A

Good lighting

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4
Q

What should we do during inspection to make sure that we are respecting the patient and keeping them comfortable?

A

Obtain adequate exposure. Only show the amount of body that you need to expose, keep other areas covered.

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5
Q

What is the second step of assessment?

A

IPPA

Palpation; using sense of touch.

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6
Q

What are things we assess with palpation?

A

texture
temperature
moisture
organ size & location
Swelling
vibration or pulsation
rigidity or spasticity
presence of lumps
presence of tenderness or pain

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7
Q

What is light palpation used for?

A

used to detect surface characteristics

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8
Q

What is deep palpation used for?

A

used for intermittent pressure to examine abdominal contents

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9
Q

What is bimanual palpation used for?

A

Used to assess deeper structures

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10
Q

What do we use the fingertips for?

A

For fine discrimination of texture, swelling, pulsation, presence of lumps

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11
Q

What is a grasping action of finger and thumb used for?

A

used to detect the shape, size, position, and consistency of an organ

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12
Q

What are the base of the fingers or ulnar surface used for?

A

To detect vibration

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13
Q

What do we use the dorsum for?

A

to detect temperature changes

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14
Q

Before palpating, what should you ask the patient?

A

Ask if they have any tender areas and then palpate these areas last.

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15
Q

What type of palpation should you always begin and end with?

A

Always begin with light palpation and move to deep palpation last

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16
Q

What is the flow of palpation?

A

Top to bottom

left to right

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17
Q

What are common areas for palpation?

A

Lymph nodes (neck)
sinuses
abdomen
spine
pulses
uterus
heart

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18
Q

How do you palpate the lymph nodes?

A

both sides of neck simultaneously

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19
Q

How do you palpate the sinuses?

A

Both sides simultaneously

20
Q

How do you palpate the abdomen?

A

in a clockwise pattern

21
Q

How do you palpate the spine?

A

top to bottom

22
Q

How do you palpate pulses?

A

simultaneously right and left

or individually

23
Q

How do you assess the uterus?

A

bimanually

24
Q

How do you palpate the heart?

A

Fingertips over the pericardium

25
Q

What is the third step of assessment?

A

IPPA

Percussion

26
Q

What is percussion?

A

Tapping the skin with short, sharp strokes that produce a vibration (with a characteristic sound) to assess underlying structures.

27
Q

T/F: Percussion can map the location and size of an organ.

A

TRUE

It can map the location and size of an organ as the sound will change as you move off/away from the organ.

28
Q

T/F: Percussion cannot measure the density of an underlying structure.

A

FALSE
percussion can measure the density of an underlying structure. Sounds will change as one percusses over air, fluid, or solid structures.

29
Q

Can percussion detect an abnormal mass?

A

yes: can be detected up to 5 cm deep.

30
Q

T/F: Percussion can determine the disease state of a structure.
Example: the kidney

A

FALSE

Percussion cannot determine the disease state but can depict the location, size, and density of an organ.

31
Q

T/F: Percussion can detect underlying inflammation.

A

TRUE

Percussion can facilitate pain, indicating underlying inflammation.

32
Q

T/F: Percussion cannot elicit a deep tendon reflex.

A

FALSE

Percussion can most definitely elicit a deep tendon reflex.

33
Q

What does the stationary hand do in the percussion technique?

A

It is usually the hyperextended middle finger, with the distal portion firmly against the skin.

Make sure to lift the rest of the hand off the skin to avoid dampening vibrations.

34
Q

What does the striking hand do in the percussion technique?

A

the top of the middle finger of the dominant hand will strike the stationary finger 2 times just behind the nail bed.

Make sure to lift off quickly and use enough force to get a clear note.

35
Q

Resonant

A

over normal lung tissue, sounds clear and hollow.

36
Q

Hyperresonant

A

Abnormal in adults, a sign of emphysema

normal over a child’s lungs

37
Q

Tympany

A

over abdomen (air-filled areas), sounds drum like

38
Q

Dull

A

over organs (liver), sounds like a muffled thud

39
Q

Flat

A

over bone, muscle, and tumor; the sound comes to a dead stop.

40
Q

Structures with more air will produce

A

A louder, longer, and deeper sound. It vibrates freely

ex. lungs

41
Q

Denser more solid structures will produce

A

A softer, higher, shorter sound. It cannot vibrate as easily.

ex. liver

42
Q

What is the fourth step of assessment?

A

IPPA

Auscultation; using sense of hearing

43
Q

What is auscultation?

A

Using a stethoscope to block out room sounds so that you can hear sounds produced by the body.

44
Q

What kind of sounds is the diaphragm of a stethoscope used for?

A

high pitched sounds

ex. lungs, abdomen, heart

45
Q

What kind of sounds is the bell of the stethoscope used for?

A

low pitched sounds

ex. vascular sounds, extra heart sounds, murmurs.

46
Q

Which of the following techniques uses the sense of touch when assessing the patient?
A Palpation
B Inspection
C Percussion
D Auscultation

A

A. Palpation

Nurse Assessment (6 decks)

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