Assessment Techniques, Vital Signs & Pain

Question 1

Inspection

Answer 1

purposeful and systematic observation

Question 2

General Survey

Answer 2

an overall review or first impression a nurse has of a person’s well being. This is done head-to-toe, or cephalo-caudal, lateral to lateral, proximal to distal, and front to back

Question 3

Palpation

Answer 3

method of examining by feeling a part with the finger or hand

Question 4

Light Palpation

Answer 4

▪ Use this technique to feel for surface abnormalities.
▪ Depress the skin ½ to ¾ inch (about 1 to 2 cm) with your finger pads, using the lightest touch possible.
▪ Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.

Question 5

Deep Palpation

Answer 5

▪ Use this technique to feel internal organs and masses for size, shape, tenderness, symmetry, and mobility.
▪ Depress the skin 1½ to 2 inches (about 4 to 5 cm) with firm, deep pressure.
▪ Use one hand on top of the other to exert firmer pressure, if needed.

Question 6

Percussion

Answer 6

an act of striking one object against another for the purpose of producing a sound; used to assess the location, shape, size, and density of body tissues

Question 7

Hyperrresonant

Answer 7

are louder and lower pitched than resonant sounds are normally heard when percussing the chests of children and very thin adults. Hyperresonant sounds may also be heard when percussing lungs hyperinflated with air, such as may occur in patients with COPD, or patients having an acute asthmatic attack. An area of hyperresonance on one side of the chest may indicate a pneumothorax.

Question 8

Resonant

Answer 8

low pitched, hollow sounds heard over normal lung tissue

Question 9

Tympanic

Answer 9

hollow, high, drumlike sounds. Tympany is normally heard over the stomach, but is not a normal chest sound. Tympanic sounds heard over the chest indicate excessive air in the chest, such as may occur with pneumothorax

Question 10

Dull

Answer 10

normally heard over dense areas such as the heart or liver. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors

Question 11

Flat

Answer 11

normally heard over solid areas such as bones

Question 12

Auscultation

Answer 12

listening for sounds within the body

Question 13

Afebrile

Answer 13

a condition in which the body temperature is not elevated

Question 14

Hyperthermia

Answer 14

high body temp

Question 15

Hypothermia

Answer 15

low body temp

Question 16

Stroke Volume

Answer 16

the volume of blood pumped from one ventricle of the heart with each beat

Question 17

Pulse Rate

Answer 17

the number of times your heart beats per minute (60-100bpm)

Question 18

Bradycardia

Answer 18

slow heart rate

Question 19

Tachycardia

Answer 19

rapid heart rate

Question 20

Sinus Arrhythmia

Answer 20

a common condition in which the heart rate varies with breathing

Question 21

Force of Pulse

Answer 21

compressibility of pulse. It is a rough measure of systolic blood pressure
0= absent
	1+= barely palpable
	2+= easily palpable
	3+= full

Question 22

Respiratory Rate

Answer 22

the number of breaths a person takes per minute (12-16 breaths per minute)

Question 23

Systolic Pressure

Answer 23

highest point of pressure on arterial walls, when ventricles contract

Question 24

Diastolic Pressure

Answer 24

least amount of pressure exerted on arterial walls, which occurs when the heart is at rest between ventricular contractions

Question 25

Pulse Pressure

Answer 25

difference between systolic and diastolic pressures

Question 26

Mean Arterial Pressure

Answer 26

the average blood pressure in an individual

Question 27

Cardiac Output

Answer 27

volume of blood pumped from the left ventricle per minute

Question 28

Diurnal Rhythm

Answer 28

relating to or occurring in a 24-hour period

Question 29

Ausculatory Gap

Answer 29

a period of diminished or absent Korotkoff sounds during the manual measurement of blood pressure

Question 30

Korotoff Sounds

Answer 30

series of sounds that correspond to changes in blood flow through an artery as pressure is released

Question 31

Oxygen Saturation

Answer 31

dissolved oxygen; a relative measure of the amount of oxygen that is dissolved or carried in a given medium

Question 32

Nocicetive Pain

Answer 32

pain that is categorized as cutaneous, deep somatic, or visceral in nature

Question 33

Neuropathic Pain

Answer 33

pain that results from an injury to or abnormal functioning of peripheral nerves or the central nervous system

Question 34

COLDERR

Answer 34

Character: Describe the sensation ( sharp, burning, aching)
Onset: When did it start, how as it changed
Location: Where is it
Duration: How long does the pain last
Exacerbation: Does anything set it off
Relief: Does anything give it relief
Radiation: Does the pain travel anywhere else