Assessment Techniques Ch.8 Flashcards
The skills requisite for the physical examination are ?
IPPA [ inspection, palpation, precussion, and ausculation]
You will always IPPA except with the ___, then you would___.
abdomen. inspection, ausculation, precussion then palpate
Palpation applies your senses of touch to assess these factors:
texture tempature moisture organ location or size swelling vibration or pulsation rigidity or spasticity crepitation presenses of lumps of masses presenses of tenderness or pain
what is best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presense of lumps?
fingertips
what is best for detecting the position, shape, and consistency of an organ or mass?
a grasping action of the fingers and thumb
best for determining temperture
the dorsa (back) of fingers and hand
best for vibration
base of fingers (metacarpophalangeal joints) or ulnar surface of the hand
Identify any tender areas, and palpate them ____.
last
what is light palpation?
1 cm deep usng finger pads with very light touch and assess for : surface abnomalities, texture, tenderness, temperature, moisture, elasticity, pulsations, superficial organs, and masses
what is deep palpation?
4 to 5 cm deep with firm, deep pressure. used to assess internal organs and masses for : size, shape, tenderness, symmetry, mobility.
what is 75% of assessment technique?
inspection
_____ requires the use of both of your hands to envelope or capture certain body parts or organs - such as kidneys, uterus, or adnexa- for more precise delimitation.
bimanual palpation
___ is tapping the person’s skin with short, sharp stroke to assess underlying structures
percussion.
The strokes yield a _____ and a characteristic sound that depicts the ___,___, and____.
palpable vibration.
location
size
density of the underlying organ
precussion can detect an abnormal mass if it is ____.
fairly superficial ( the percussion vibration penetrate about 5 cm deep; a deeper mass would give no change in percussion)
percussing over a bone yeilds no data because it sounds ___.
dull
uses 1 or 2 fingers to tap directly on the body part. for wht?
direct percussion
tenderness of sinuses
elicits sounds that give clues to the makeup of the underlying tissue.
- used to locate organ borders
- identify organ shape and position
- determine if an organ is solid or filled with gas/fluid
indirect percussion
form of indirect percussion
-used to asses for tendernes of the _______.
fist percussion
-liver and kidneys
percussion sound over muscle or bone? (no air present, over tumor)
flatness
percussion sound over organs (dense..like liver or spleen)
dullness
percussion sound over normal lungs
resonance
percussion sounds not normal in adults (with increased amounts of air like emphysema) but normal in lungs of children
hyperresonance
percussion sound over gastric air bubble and abdomen.. ( air filled viscus; stomach or intestines)
tympany
best for high pitched sounds—-breath,bowel, and normal heart sounds.
diaphragm
It is best for soft, low pitched sounds such as extra heart sounds or murmurs.
bell endpiece
Name & describe the four components or sounds to listen for during percussion
Amplitude- is the sound’s intensity, which may be loud or soft.
Pitch- describes the number of vibrations per second and may be high-pitched or low-pitched.
Quality (or timbre)- is the subjective difference due to a sound’s distinctive overtones.
Duration- is the length of time the note lingers.
What are the most commonly auscultated areas?
The heart, blood vessels, lungs, and abdomen
When performing indirect percussion, where is the stationary finger struck?
at the distal interphalangeal joint
The best description of the pitch of a sound wave obtained by percussion is:
the number of vibrations per second.
The bell of the stethoscope is used for what pitch of sounds?
soft-low pitched sounds
an instrument that illuminates the ear canal, enabling the examiner to look at the ear canal and tympanic membrane
otoscope
the length of time the note lingers
duration
(or timbre) a subjective difference due to a sound’s distinctive overtones
quality
(or frequency) the number of vibrations (or cycles) per second of a note
pitch
(or intensity) how loud or soft a sound is
amplitude
an instrument that illuminates the internal eye structures, enabling the examiner to look through the pupil at the fundus of the eye
ophthalmoscope
an infection acquired during hospitalization
nosocomial infection
What are the three “methods” or “styles” of palpation and what are they used for?
Palpation may be light, deep, or bimanual. Light palpation evaluates surface characteristics and identifies areas of tenderness. Deep palpation assesses an organ or mass deeper in a body cavity. Bimanual palpation is the use of both hands to envelop or capture certain body parts or organs, such as the kidneys
Deep palpation is used to:
A. identify abdominal contents. .
B. evaluate surface characteristics.
C. elicit deep tendon reflexes.
D. determine the density of a structure
A. Identify abdominal contents.
Amplitude is:
A. the intensity (soft or loud) of sound.
B. the length of time the note lingers.
C. the number of vibrations per second.
D. the subjective difference in a sound’s distinctive overtones.
A. the intensity (soft or loud) of sound.
The dorsa of the hands are used to determine:
A. vibration.
B. temperature
C. an organ’s position.
D. fine tactile discrimination.
B. Tempature
Fine tactile discrimination is best achieved with the:
A. opposition of the fingers and thumb.
B. fingertips.
C. back of the hands and fingers.
D. base of the fingers.
B. Fingertips
Which of the following is considered when preparing to examine an older adult?
A. Base the pace of the examination on the patient’s needs and abilities.
B. Avoid physical touch to offset making the older adult uncomfortable.
C. Be aware that loss will result in poor coping mechanisms.
D. Confusion is a normal, expected finding in an older adult.
A
When performing percussion, the examiner:
A. strikes the flank area with the palm of the hand.
B. strikes the stationary finger at the distal interphalangeal joint.
C. strikes the stationary finger at the proximal interphalangeal joint.
D. taps fingertips over bony processes.
B. strikes the stationary finger at the distal interphalangeal joint.
When should the examiner use hand washing instead of an alcohol-based hand rub?
A. if the patient has an infection with Mycobacterium tuberculosis
B. if the patient has an infection with Clostridium difficile
C. if the patient has an infection with hepatitis B virus
D. if the patient is HIV positive
B. if the patient has an infection with Clostridium difficile
When performing a physical assessment, the technique the nurse will always use first is: A) Percussion B) Inspection C) Palpation D) Auscultation
B. Inspection
The nurse is assessing a patient’s skin during an office visit. What is the best technique to use to best assess the patient’s skin temperature?
A) Use the fingertips because they’re more sensitive to small changes in temperature.
B) Use the palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.
C) Use the dorsal surface of the hand because the skin is thinner than on the palms.
D) Use the ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity.
C) Use the dorsal surface of the hand because the skin is thinner than on the palms
The nurse would use bimanual palpation technique in which situation?
A) Palpating the thorax of an infant
B) Palpating the kidneys and uterus
C) Assessing pulsations and vibrations
D) Assessing the presence of tenderness and pain
B) Palpating the kidneys and uterus
