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Health Assessment > Ch 3 Techniques Of Assessment And Safety > Flashcards

Ch 3 Techniques Of Assessment And Safety Flashcards

1
Q

What is one of the first things you want to do during a physical exam with injury or no injury

A

You want to inspect and compare the well v the injured/ affected

AKA: comparing bilateral body parts even if not injured

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2
Q

Give the physical assessment techniques in order from first to last and give a brief discription

A
  1. Inspection: observing visually and smelling
  2. Palpation: touching skin and organs
  3. Percussion: tapping to determine solid or air/fluid filled areas of body
  4. Auscultation: hearing movement of air/ fluid in body using stethoscope
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3
Q

When physically assessing patient what are important things to tell patient before beginning (2 things)

A

(1) tell patient what you’re going to do
- for Trust and rapport

(2) inform patient you’ll be taking notes during physical assessment

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4
Q

 What is inspection and what is inspected during the physical assessment

(Give all related info)

A

Inspecting is observing VISUALLY and SMELLING NO TOUCHING

You’re inspecting:

  • skin color
  • facial expressions
  • dress
  • movement

You’re smelling for

  • B.O
  • tobacco
  • urine
  • stool
  • alcohol
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5
Q

What is palpation and what are you palpating

A

Palpation is (clinical) touching and you are palpating skin and organs

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6
Q

What is percussion and what are the types of percussions

A

percussion is the tapping to determine solid or air/ fluid filled body areas

•Direct percussion: fingers directly on skin

•Indirect percussioninb: placing non-dominant hand so dominant hand can tap on middle finger
- includes CVA (coastal vertebral angle)
Placing nondominant hand over their backs were kidneys are in forecast for fist. Used to assess pain or tenderness if UTI to show kidney infection if pain

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7
Q

Define auscultation and list some common things auscultated

A

Auscultation is hearing the movement of air or fluids in the body systems with a stethoscope

Assessing: 
-b. Vessels (broui: b. Vessel blockage)
- blood pressure 
-Heartsounds (S1,S2, murmur, S3,S4) 
-lung sounds
- apical pulse
-abdominal sounds
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8
Q

What is the most important action to prevent transmission and infection

A

Hand hygiene

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9
Q

What can you do to help gain trust with your patient upon physical assessment and how for long?

A

Wash your hands in front of the patients for a minimum of 20 seconds

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10
Q

When is a good time to perform hand hygiene in relation to patient contact to avoid pt-nurse-pt contamination and what technique do you use

A

” Gel in and Gel out” with 2 pumps and rub until dry

Gel before entering patient’s room and upon exiting

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11
Q

What happens if you don’t gel in and gel out

A

You’re transferring organisms by contamination of one patient to the next

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12
Q

When should you use gel

5 instances

A
  • On non-soiled hands
  • patient contact pre-and post with intact skin “gel in and gel out”
  • when moving from a contaminated area to a non-contaminated area on the patient
  • After touching objects in patient area
  • After gloves
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13
Q

When should you wash your hands

3 instances

A
  • When hands are visibly soiled
  • after eating/the bathroom
  • after coming in contact with C. Diff
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14
Q

When should you wear gloves

3 situations

A

When dealing with :

  1. secretions
  2. lesions
  3. hair
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15
Q

When should you change your gloves

A

When visibly contaminated

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16
Q

When should you remove your gloves

A

Before leaving the patient’s room and before touching computer

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17
Q

What is the purpose of standard precautions and who are they used on

A

Purpose: to prevent disease transmission during contact With non-intact skin , mucous membranes, body substances, blood

Used in all patients, visitors and stuff

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18
Q

Why do nurses develop a latex allergy and how do you prevent exposure

A

Nurses develop a latex allergy due to continuous exposure

Prevent exposure by asking for nitrile gloves

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19
Q

If your hands become dry from constant washing is skin moisturizer allowed

A

Yes, non perfumed

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20
Q

Give the four physical assessment techniques in order

A
  1. inspection
  2. Palpation
  3. percussion
  4. auscultation
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21
Q

What is inspection and what do you want to do to your patient before you even begin in regards to consent

A

Inspection is observing VISUALLY and SMELLING

you want to inform your patient you need to look at their body and always ask permission

“is it okay”

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22
Q

 during inspection what kind of exposure is needed and for what is it needed (in bed pt)

A

Adequate exposure is needed to see everybody part even turning pt to see back

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23
Q

What are characteristics for inspection (9)

A
  1. Physical characteristics; odor
    • B.O, tobacco, urine, stool, alcohol
  2. Behaviors
    • calm, agit, anxious
  3. Age; gender
  4. level of alertness
    • A&o x 4
    • if in coma pinch to assess alert to pain
  5. Body shape, size
    • tall, sure, obese, Apple, pear shape
  6. Skin color
    • White(anemia) , red( CO2 poison) blue (cyanotic), yellow (hepatic issue)
  7. Hygiene
    • lice, scabies, mouth, teeth, hair
  8. Posture
  9. Level of comfort/anxiety
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24
Q

How do you ensure you are maintaining modesty while getting adequate exposure

Give example of older and adolescence

A

You expose what you need and dress as you go

Older: give blanket due to being cold
Adolescence: body image issues

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25
Q

Why must you document your inspection data accurately

A

Accurate descriptions are essential for legal and communication of findings to others

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26
Q

During an inspection why should you remove an assisting device on the patient like a splint

A

To facilitate a complete inspection

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27
Q

Define palpation And give sequence number as part of the four physical assessment techniques

A

Palpation is touch of the skin or organs and it is the 2nd technique used

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28
Q

What are different things that you can palpate

A

Texture, temperature (dorsal side of hand), moisture, size shape

Any vibration( ulnar assessment of thorax) crepitus(Rice Krispie under skin) tenderness, pain ,or edema

29
Q

What is used for fine discrimination during Palpation

And what does it help identify during the patient assessment

A

The finger pads of two fingers like if you were to assess a Pulse

Palpation helps assess pulses, small lumps, skin texture and edema(1 finger)

30
Q

What is the Allen test and what is used to assess it

A

The Allen test is a test of blood flow of the artery of the ulnar region and the finger pads for fine discrimination are used

31
Q

When do you use a palm to palpate

A

During abdominal assessment

32
Q

When do you use the dorsal side of your hand to palpate

A

When you’re assessing temperature

33
Q

How deep is light palpation and what is it used to on a patient

A

Light palpation is 1 cm deep you can use it to begin with then proceed to moderate palpation

34
Q

When is light palpation appropriate to use (big category and sub categories)

A

For surface characteristics like the skin

  • surface
  • lesions
  • temperature
35
Q

How deep is moderate palpation and when is it used

A

Moderate palpation is 1 to 2 cm deep and is used to assess abdominal organ characteristics

36
Q

What is the hand position for moderate palpation

A

Use pressure from both hands and or the palm surface

37
Q

Because moderate palpation is used to assess abdominal organs what is vital to do when palpating the abdomen

A

It is vital to look at the patient’s face when palpating the abdomen to identify any tenderness with patient grimacing

38
Q

If a patient has suspected appendicitis or peritonitis where with their pain be located?

What palpation assessment is done to assess and describe it

A

With appendicitis or peritonitis there will be pain in the right lower quadrant

A rebound tenderness assessment is done for appendicitis where you press away from the area and ask
—— “does it hurt more when I press down or let go”

39
Q

What is percussion and what is the sequential number in the physical assessment techniques

A

Percussion is to tap and produce sounds

Percussion is number 3 on the list of physical assessment techniques

40
Q

What types of percussion techniques are there

2

A

Direct percussion: tap finger directly on skin

Indirect percussion: using nondominant hand as a barrier and tapping over middle finger
-coastal vertebral angle (CVA)
A form of indirect percussion were you percuss with your fist on a patient’s lower back where their kidneys are to see if there is pain or tenderness if a patient has a UTI to see if the patient has a kidney infection

41
Q

Where do you use indirect percussion On a patient

A

Over lungs and the abdomen

42
Q

What are the types of tissues used to conduct sound and what kind of tones do they create

A

Dense tissue (bones): quiet tone

Air/fluid (lungs and stomach): louder tone

43
Q

List the five types of percussion tones and the sites the sounds originate from

A
  1. Flat - bone/muscle
    • very full
  2. Dull- organs (liver)
    • like a thud
  3. Resonate aka hallow- bowel/lungs
    • hallow
  4. tympanic - over abdomen
    • drum like
  5. hyperresonance- emphysema/COPD
    • booming
44
Q

What is auscultation and the listed number in the physical assessment techniques

A

Auscultation is using a stethoscope to listen

Auscultation is number for any physical assessment techniques

45
Q

When auscultating what does sound vary with

A

Sound varies with movement of air and fluids, narrow/dilated spaces

46
Q

What are things that can be auscultated

A
  • b. vessels (Broui: blocked blood vessel)
  • BP
  • Heart sounds (S1, S2, murmur, S3, S4)
  • lung sounds
  • apical pulse
  • abdominal sounds
47
Q

What are descriptor qualities used to describe auscultation

A
  1. intensity
  2. pitch
  3. duration
  4. quality
48
Q

How does an abdominal assessment differ from any other normal assessment in the sequence of physical assessment techniques

A

When auscultation is done

Abdominal assessment

  1. inspection (observe visually / smell)
  2. Auscultation ( listen)
  3. Palpation (touch)
  4. Percussion (tap)

Normal Assessment

  1. Inspection ( observe visually/ smell)
  2. Palpation (touch)
  3. Percussion( tap)
  4. Auscultation(listen)
49
Q

What is the main tool used for auscultation And what is it used for

A

Stethoscope, Used for listening to sounds not normally heard

50
Q

What does a stethoscope not do v What does a stethoscope do

A

A stethoscope does not amplify sound but conducts sound and blocks environmental noise

51
Q

What should you Do in between patients with your stethoscope and when should you do it, why should you do it?

A

You should clean your stethoscope with an alcohol swab in between patients and in front of your patient to build trust and rapport

52
Q

When looking at the ear tips of the stethoscope how should they fit in your ear and how should they face

A

The ear tips should fit snug and comfortable and they should be tilted forward to your patient and nose

53
Q

 What is a chest piece of a stethoscope

A

The chest piece is both the diaphragm (big) and the bell (small)

54
Q

 What type of sounds are the diaphragm and bell used for and how should you press it into your patient

A

The diaphragm is used for most sounds like heart and lungs and you should press firmly

The bell is used for low pitch sounds like a Heartsounds (MURMUR) ans you should lightly press it into your patient

55
Q

What frequency can you hear with light contact of a stethoscope? what frequency can you hear with firm contact of a stethoscope

A

Light contact = low frequency sound

Firm contact = high frequency sound

56
Q

What do you do with your stethoscope in between patients

A

In between patients you should clean your stethoscope with alcohol swabs in front of your patient to build trust and rapport

57
Q

Is listening with a stethoscope over clothing OK

A

No, you should make direct contact with skin

58
Q

How should you hold the chest piece of the stethoscope when auscultating

A

Between your index and middle finger

59
Q

What do you use an ophthalmoscope for

A

Opthal has p for pupil So it is used to visualize the interior eye structure

60
Q

What does an otoscope help examine and how does it differ between adults and children

A

The ears and nose

Ears:

 - adult: up and back
  - Child: down and back
61
Q

What does a tuning fork help identify

A

Hearing discrepancies (loss) through vibrations

62
Q

How do you asses a weber test With a tuning fork

A

It is placed on the top of the head to see which ear is louder

63
Q

How do you assess a rinne test With a tuning fork

A

Both air and bone ( mastoid)

64
Q

Give the reason of use for each equipment listed

  1. Reflex hammer
  2. vaginal speculum
  3. Goniometer
  4. Skinfold calipers
A

1. Deep tendon reflexes

  1. Pap smears
  2. Range of motion / angle of patient joint 
  3. Skinfold thickness
65
Q

Why should you gather all your equipment before completing a physical assessment

A

To avoid disruptions so you gain patients trust

66
Q

In a hospital setting doing a general assessment of Vital signs what are common equipment

A
  • Thermometer
  • Watch
  • Stethoscope With alcohol swabs
  • Blood pressure cuff
  • people flashlight
  • scale that’s calibrated to 0
67
Q

What is important to remember when weighing your patient

A

Use the same scale each time with patient wearing same type of clothing each time

68
Q

What areas should deep palpation not be used

A

Areas the pose a risk to patient like an enlarged spleen or inflamed appendix

Health Assessment (20 decks)

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