Assessment Techniques, Vital Signs & Pain Flashcards
Inspection
purposeful and systematic observation
General Survey
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
Palpation
method of examining by feeling a part with the finger or hand
Light Palpation
▪ 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.
Deep Palpation
▪ 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.
Percussion
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
Hyperrresonant
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.
Resonant
low pitched, hollow sounds heard over normal lung tissue
Tympanic
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
Dull
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
Flat
normally heard over solid areas such as bones
Auscultation
listening for sounds within the body
Afebrile
a condition in which the body temperature is not elevated
Hyperthermia
high body temp
Hypothermia
low body temp
Stroke Volume
the volume of blood pumped from one ventricle of the heart with each beat
Pulse Rate
the number of times your heart beats per minute (60-100bpm)
Bradycardia
slow heart rate
Tachycardia
rapid heart rate
Sinus Arrhythmia
a common condition in which the heart rate varies with breathing
Force of Pulse
compressibility of pulse. It is a rough measure of systolic blood pressure 0= absent 1+= barely palpable 2+= easily palpable 3+= full
Respiratory Rate
the number of breaths a person takes per minute (12-16 breaths per minute)
Systolic Pressure
highest point of pressure on arterial walls, when ventricles contract
Diastolic Pressure
least amount of pressure exerted on arterial walls, which occurs when the heart is at rest between ventricular contractions
