Basic Assessment Flashcards
Sitting position listens for:
listening to heart, lungs, BP
Supine position
checking skin, pulses, swelling
Basic assessment order
Inspect
Palpate
Percussion
Auscultation
Least invasive to most invasive
inspection
Hear movements of air, blood, or fluid in the body over lungs & abdomen
Auscultation
What are you listening for when you are using stethoscope?
intensity, pitch, duration, and quality
Optimize quality of findings for auscultation?
Quiet room
Stethoscope directly on skin
If client is cold and shivers—may interfere
Friction of body hair rubbing–could mistaken for abnormal lung sounds (crackles)
Percussion is evaluated to: 3
Evaluate size, borders, and consistency of internal organs
Detect tenderness
Determine extent of fluid in a body cavity
percussion sounds determine:
location, size, and density of structures
tapping over middle finger
indirect percussion
ex: percuss over lung tissue
striking finger or hand directly against client’s body
direct percussion
five percussion tones
Tympany Resonance Hyperresonance Dullness Flatness
loud, high-pitched sound heard over abdomen
Tympany
heard over normal lung tissue
Resonance
heard in overinflated lungs, as in emphysema
hyperresonance
Heard over liver
dullness
heard over bone & muscle
Flatness
Use of hands to feel texture, size, shape, consistency, location of certain parts, and identify painful or tender areas
Palpation
With palpation, what are you measuring for skin? (6)
Temp moisture texture turgor tenderness thickness
With palpation, what are you measuring for abdomen? (3)
tenderness, distension or masses
What part of hands are more sensitive?
palmar surface & finger tips
Ulnar surface of hand to fifth finger is
is most sensitive to vibration
Dorsal surface is better for
assessing temperature
Light palpation is
1 cm
light palpation is used to assess
assess skin, pulsations, and tenderness
deep palpation is what depth? and what does it assess?
4 cm & used to determine organ size and contour
palpation uses both hands, one anterior, one posterior, to entrap an organ or mass between fingertips to assess size and shape
Bimanual palpation
assessment steps for abdomen
Inspect
Auscultate
Percuss
Palpate
