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NSG2317 - health assessment > Assessment Techniques + Vital Signs > Flashcards

Assessment Techniques + Vital Signs Flashcards

1
Q

4 Moments of Hand Hygiene

A
  1. before initial patient/ patient environment contact
  2. before aseptic procedures
  3. after bodily fluid exposure risk
  4. after patient/ patient environment contact
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2
Q

Assessment Techniques

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Ausculation
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3
Q

Inspection

A

concentrated watching –> visual evaluation of the patient as a whole THEN individual systems

  • performed first
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4
Q

Palpation

A

physical contact with/ manipulation of the target structure –> used to confirm points noted during the initial inspection

assesses:
- texture: rigidity, spasticity, crepitation
- temperature, moisture
- organ location and size
- potential swelling
- vibration, pulsation
- presence of lumps or masses
- tenderness, pain

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5
Q

Palpation: Steps

A
  1. Warm hands
  2. Select anatomy of focus, ensure adequate (but limited) exposure
  3. perform superficial palpation, then progress to deep palpation if necessary
    • use intermittent pressure not continuous
    • use the pads of your fingers
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6
Q

Superficial Palpation

A

surface level <1cm deep
uses 1-2 hands

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7
Q

Deep Palpation

A

3-4cm deep
usually uses two hands

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8
Q

Palpation Technique: Fingertips

A
  • fine tactile discrimination - texture
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9
Q

Palpation Technique: Grasping of Fingers + Thumbs

A
  • position
  • shape
  • size
  • consistency
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10
Q

Palpation Technique: Back of Hands or Fingers

A
  • temperature
  • moisture
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11
Q

Palpation Techniques: Base of Fingers or Knuckles

A
  • vibrations
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12
Q

Percussion

A

the tapping of skin with short, sharp strokes to assess underlying structures with sound

sound can indicate the: location, size, and density of underlying organs

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13
Q

Direct Percussion

A

the striking hand makes direct contact with the patient’s skin
- uses only one hand (striking)

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14
Q

Indirect Percussion

A

the striking hand makes indirect contact with the patient’s skin, striking the stationary hand instead
- uses two hands (stationary and
striking)

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15
Q

Percussion: Steps

A
  1. flex the non-dominant hand so that the middle finger is hyperextended downwards
  2. position the hyperextended middle finger on the patient’s skin on the location you want to percuss - ensure no other fingers touch the skin (dampen sounds)
  3. strike just below the nail bed of the stationary hand’s middle finger with the tip of the dominant hand’s middle finger
  4. strike each location twice before moving to a new location
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16
Q

Percussion Sounds: Dense Tissue

A

volume - dull thud
pitch - low, dense, muscular
duration - very short, solid, no echo
quality - description of sound

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17
Q

Percussion Sounds: Air-Filled Tissue

A

volume - loud, hollow
pitch - high, hollow
duration - long, echo (hollow space)
quality - description of sound

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18
Q

Ausculation

A

listening to sounds produced by parts of the body using a stethoscope

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19
Q

Artifacts to Avoid

A
  1. ensure direct contact with skin - clothing can create excess noise
  2. avoid your own artifact - ensure that your clothing, hair, or otherwise do not bump into the stethoscope to create additional sounds
  3. keep the room warm - cold rooms may cause the patient to shiver, creating addition noise (muscle contractions)
  4. unnecessary friction - wet hair (chest hair, etc) prior to auscultation to avoid artifacts from the friction
  5. ensure a private, quiet room - background noises can create a “roaring” in the stethoscope
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20
Q

Stethoscope: bell

A

deep, hollow, low-pitched sounds
- extra heart sounds
- murmurs

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21
Q

Stethoscope: diaphragm

A

high-pitched sounds
- bowel noises
- normal breath sounds
- manual blood pressure readings

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22
Q

Vital Signs (5)

A
  1. Temperature
  2. Pulse
  3. Respiratory Rate
  4. pulse Oximetry
  5. Blood Pressure
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23
Q

Additional Vital Signs (2)

A
  1. Pain (Assessment)
  2. Level of Consciousness
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24
Q

Normal Temperature

A

35.8 - 37.3 C

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25
Temperature Locations
1. Oral 2. Axillary 3. Tympanic Membrane 4. Rectal 5. Temporal
26
Temperature: Influencing Factors
1. Diurnal Cycle - temp fluctuates 1.5C throughout the day (lowest in the morning, highest in the evening) 2. Menstruation Cycle - increases temp (progesterone) 3. Exercise + Stress - SNS stimulation increases temp temporarily 4. Consumption - - hot/ cold drinks changes the temp of the mouth - chew gum moves the mandible which increases oral temp - smoking dilates vessels increasing oral temp 5. Age - decreases with age
27
Oral Temperature
place covered probe (blue cover) under the tongue in one of the two sublingual pockets - close mouth and wait - ensure thermometer is set to adult oral and is in C - dispose of cover immediately after
28
When NOT to take an oral temperature
- when the patient is unable to close their mouth (child, intubated) - when the patient cannot follow instructions - when the patient is unconscious
29
Axillary Temperature
place covered probe (blue cover) into the axillary pocket and close arm - wait for reading - ensure the thermometer is set to adult axillary and in C - dispose cover immediately after - do NOT use for adults
30
Rectal Temperature
1. patient positioned on their left side with knees pulled up to their chest 2. hand hygiene, don gloves, and place red probe cover on thermometer 3. lubricate thermometer probe and insert in the direction of the umbilicus NO MORE than 1inch (2-3 cm) - hold and wait for reading 4. dispose of probe immediately
31
When to take a rectal temperature
To be used when other routes are not practical - when the patient is unconscious (coma) - when the patient cannot follow instruction - the patient cannot close their mouth (children, intubation)
32
Tympanic Membrane Temperature
pull the helix of the ear up and back to straighten ear cannal, place cover on thermometer, and place probe into the ear in the direction of the nose - ensure the thermometer is set to C - look inside the ear canal for ear wax that could interfere with reading
33
Temporal Temperature
place the thermometer in the middle of the patient's forehead, slide along the hairline to one side, and finish behind th ear - less accurate - should be used as an additional reading, but not on its own
34
Hyperthermia
>38 C
35
Hypothermia
<35 C
36
9 Pulse Points
1. Temporal 2. Carotid 3. Apical Impulse 4. Brachial 5. Radial 6. Femoral 7. Popliteal 8. Anterior tibialis 9. Dorsalis Pedis
37
Normal Heart Rate
50-95 bpm
38
Tachycardia
> 95 bpm
39
Bradycardia
< 50 bpm
40
Pulse Assessment
a. Rate - within, above, or below normal range b. Rhythm - regular or irregular c. Force - 0, 1+, 2+, 3+ d. Equality - bilateral, equal
41
Normal Respiratory Rate
10 - 20 breaths per minute
42
Tachypnea
> 20 breaths per minute
43
Bradypnea
< 10 breaths per minute
44
Respiratory Assessment`
a. Rate b. Effort c. Rhythm d. Depth e. sound
45
Pulse Oximetry (definition)
amount of oxygen reaching the tissues
46
Normal Pulse Oximetry
> 95%
47
Normal Blood Pressure
(<) 120 / 80
48
(5) Factors Determining Blood Pressure
1. Cardiac Output 2. Vascular Resistance 3. Blood Volume 4. Blood Viscosity 5. Elasticity of Vessel Walls
49
Factors Affecting BP: Physiology
50
Factors Affecting BP: Situational
51
Korotkoff's Sounds
Phase 1 - appearance of a thumping sound = systolic value Phase 4 - muffling of the thumping sound Phase 5 - thumping sound disappears, complete silence = diastolic value
52
Orthostatic Hypotenison
an extreme change in blood pressure that occurs when the patient changes position - dehydration - hypertension + new htn meds - history of syncope Abnormal Changes: systolic dec > 20 diastolic dec > 10 pulse inc > 20
53
Hypotension
< 90/60 mmHg - vasodilation (dec resistance) - hemorrhage (dec blood volume) - acute MI (occlusions, heart muscle dies) Symptoms: - pallor, dizziness, confusion - low perfusion (esp. to brain) - tachycardia - compensation for low BP
54
Hypertension
> 130/ 90 mmHg - arteriosclerosis *increases risk for strokes*
55
Elevated Blood Pressure Value
120-129/80 mmHg
56
Hypertension Stage I Value
130/ 80-89 mmHg
57
Hypertension Stage II Value
>140/ 90 mmHg
58
Blood Pressure Errors
1. Activation of the SNS (emotion, stress, exercise) 2. <1-2 mins between readings 3. incorrect arm position 4. incorrect cuff size 5. incorrect deflation of the cuff
59
BP Error: Incorrect Cuff Size
too big = inc BP too small = inc BP
60
BP Error: <2mins between readings
inc diastolic BP - some blood will still be flowing and get trapped, leading to an artificially high diastolic reading
61
BP Errors: Arm Position
above heart - dec BP (gravity assists) below heart - inc BP (working against gravity)
62
BP Errors: Deflating the Cuff
too quickly - dec systolic, inc diastolic too slowly - inc diastolic halting/ reinflating - dec diastolic
63
Choosing the correct bladder length (BP cuff)
width = 80% arm circumference length - 80-100% arm circumference
64
Normal Vital Signs
temperature - 35.8-37.3 pulse - 50-95 bpm respirations - 10-20 breaths per min pulse oximetry - >95% blood pressure - 120/80
65
Abnormal Vital Signs
temperature - <35 or >38 pulse - <50 or >95 respirations - <10 or > 20 pulse oximetry - <95% blood pressure - <90/60 or > 130/80

NSG2317 - health assessment (18 decks)

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