Ch 3 Techniques Of Assessment And Safety Flashcards
What is one of the first things you want to do during a physical exam with injury or no injury
You want to inspect and compare the well v the injured/ affected
AKA: comparing bilateral body parts even if not injured
Give the physical assessment techniques in order from first to last and give a brief discription
- Inspection: observing visually and smelling
- Palpation: touching skin and organs
- Percussion: tapping to determine solid or air/fluid filled areas of body
- Auscultation: hearing movement of air/ fluid in body using stethoscope
When physically assessing patient what are important things to tell patient before beginning (2 things)
(1) tell patient what you’re going to do
- for Trust and rapport
(2) inform patient you’ll be taking notes during physical assessment
 What is inspection and what is inspected during the physical assessment
(Give all related info)
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
What is palpation and what are you palpating
Palpation is (clinical) touching and you are palpating skin and organs
What is percussion and what are the types of percussions
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
Define auscultation and list some common things auscultated
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
What is the most important action to prevent transmission and infection
Hand hygiene
What can you do to help gain trust with your patient upon physical assessment and how for long?
Wash your hands in front of the patients for a minimum of 20 seconds
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
” Gel in and Gel out” with 2 pumps and rub until dry
Gel before entering patient’s room and upon exiting
What happens if you don’t gel in and gel out
You’re transferring organisms by contamination of one patient to the next
When should you use gel
5 instances
- 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
When should you wash your hands
3 instances
- When hands are visibly soiled
- after eating/the bathroom
- after coming in contact with C. Diff
When should you wear gloves
3 situations
When dealing with :
- secretions
- lesions
- hair
When should you change your gloves
When visibly contaminated
When should you remove your gloves
Before leaving the patient’s room and before touching computer
What is the purpose of standard precautions and who are they used on
Purpose: to prevent disease transmission during contact With non-intact skin , mucous membranes, body substances, blood
Used in all patients, visitors and stuff
Why do nurses develop a latex allergy and how do you prevent exposure
Nurses develop a latex allergy due to continuous exposure
Prevent exposure by asking for nitrile gloves
If your hands become dry from constant washing is skin moisturizer allowed
Yes, non perfumed
Give the four physical assessment techniques in order
- inspection
- Palpation
- percussion
- auscultation
What is inspection and what do you want to do to your patient before you even begin in regards to consent
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”
 during inspection what kind of exposure is needed and for what is it needed (in bed pt)
Adequate exposure is needed to see everybody part even turning pt to see back
What are characteristics for inspection (9)
- Physical characteristics; odor
- B.O, tobacco, urine, stool, alcohol
- Behaviors
- calm, agit, anxious
- Age; gender
- level of alertness
- A&o x 4
- if in coma pinch to assess alert to pain
- Body shape, size
- tall, sure, obese, Apple, pear shape
- Skin color
- White(anemia) , red( CO2 poison) blue (cyanotic), yellow (hepatic issue)
- Hygiene
- lice, scabies, mouth, teeth, hair
- Posture
- Level of comfort/anxiety
How do you ensure you are maintaining modesty while getting adequate exposure
Give example of older and adolescence
You expose what you need and dress as you go
Older: give blanket due to being cold
Adolescence: body image issues
Why must you document your inspection data accurately
Accurate descriptions are essential for legal and communication of findings to others
During an inspection why should you remove an assisting device on the patient like a splint
To facilitate a complete inspection
Define palpation And give sequence number as part of the four physical assessment techniques
Palpation is touch of the skin or organs and it is the 2nd technique used
What are different things that you can palpate
Texture, temperature (dorsal side of hand), moisture, size shape
Any vibration( ulnar assessment of thorax) crepitus(Rice Krispie under skin) tenderness, pain ,or edema
What is used for fine discrimination during Palpation

And what does it help identify during the patient assessment
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)
What is the Allen test and what is used to assess it
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
When do you use a palm to palpate
During abdominal assessment
When do you use the dorsal side of your hand to palpate
When you’re assessing temperature
How deep is light palpation and what is it used to on a patient
Light palpation is 1 cm deep you can use it to begin with then proceed to moderate palpation
When is light palpation appropriate to use (big category and sub categories)
For surface characteristics like the skin
- surface
- lesions
- temperature
How deep is moderate palpation and when is it used
Moderate palpation is 1 to 2 cm deep and is used to assess abdominal organ characteristics
What is the hand position for moderate palpation
Use pressure from both hands and or the palm surface
Because moderate palpation is used to assess abdominal organs what is vital to do when palpating the abdomen
It is vital to look at the patient’s face when palpating the abdomen to identify any tenderness with patient grimacing
If a patient has suspected appendicitis or peritonitis where with their pain be located?
What palpation assessment is done to assess and describe it
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”
What is percussion and what is the sequential number in the physical assessment techniques
Percussion is to tap and produce sounds
Percussion is number 3 on the list of physical assessment techniques
What types of percussion techniques are there
2
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
Where do you use indirect percussion On a patient
Over lungs and the abdomen
What are the types of tissues used to conduct sound and what kind of tones do they create
Dense tissue (bones): quiet tone
Air/fluid (lungs and stomach): louder tone
List the five types of percussion tones and the sites the sounds originate from
- Flat - bone/muscle
- very full
- Dull- organs (liver)
- like a thud
- Resonate aka hallow- bowel/lungs
- hallow
- tympanic - over abdomen
- drum like
- hyperresonance- emphysema/COPD
- booming
What is auscultation and the listed number in the physical assessment techniques
Auscultation is using a stethoscope to listen
Auscultation is number for any physical assessment techniques
When auscultating what does sound vary with
Sound varies with movement of air and fluids, narrow/dilated spaces
What are things that can be auscultated
- b. vessels (Broui: blocked blood vessel)
- BP
- Heart sounds (S1, S2, murmur, S3, S4)
- lung sounds
- apical pulse
- abdominal sounds
What are descriptor qualities used to describe auscultation
- intensity
- pitch
- duration
- quality
How does an abdominal assessment differ from any other normal assessment in the sequence of physical assessment techniques
When auscultation is done
Abdominal assessment
- inspection (observe visually / smell)
- Auscultation ( listen)
- Palpation (touch)
- Percussion (tap)
Normal Assessment
- Inspection ( observe visually/ smell)
- Palpation (touch)
- Percussion( tap)
- Auscultation(listen)
What is the main tool used for auscultation And what is it used for
Stethoscope, Used for listening to sounds not normally heard
What does a stethoscope not do v What does a stethoscope do
A stethoscope does not amplify sound but conducts sound and blocks environmental noise
What should you Do in between patients with your stethoscope and when should you do it, why should you do it?
You should clean your stethoscope with an alcohol swab in between patients and in front of your patient to build trust and rapport
When looking at the ear tips of the stethoscope how should they fit in your ear and how should they face
The ear tips should fit snug and comfortable and they should be tilted forward to your patient and nose
 What is a chest piece of a stethoscope
The chest piece is both the diaphragm (big) and the bell (small)
 What type of sounds are the diaphragm and bell used for and how should you press it into your patient
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
What frequency can you hear with light contact of a stethoscope? what frequency can you hear with firm contact of a stethoscope
Light contact = low frequency sound
Firm contact = high frequency sound
What do you do with your stethoscope in between patients
In between patients you should clean your stethoscope with alcohol swabs in front of your patient to build trust and rapport
Is listening with a stethoscope over clothing OK
No, you should make direct contact with skin
How should you hold the chest piece of the stethoscope when auscultating
Between your index and middle finger
What do you use an ophthalmoscope for
Opthal has p for pupil So it is used to visualize the interior eye structure
What does an otoscope help examine and how does it differ between adults and children
The ears and nose
Ears:
- adult: up and back - Child: down and back
What does a tuning fork help identify
Hearing discrepancies (loss) through vibrations
How do you asses a weber test With a tuning fork
It is placed on the top of the head to see which ear is louder
How do you assess a rinne test With a tuning fork
Both air and bone ( mastoid)
Give the reason of use for each equipment listed
- Reflex hammer
- vaginal speculum
- Goniometer
- Skinfold calipers
1. Deep tendon reflexes
- Pap smears
- Range of motion / angle of patient joint 
- Skinfold thickness
Why should you gather all your equipment before completing a physical assessment
To avoid disruptions so you gain patients trust
In a hospital setting doing a general assessment of Vital signs what are common equipment
- Thermometer
- Watch
- Stethoscope With alcohol swabs
- Blood pressure cuff
- people flashlight
- scale that’s calibrated to 0
What is important to remember when weighing your patient
Use the same scale each time with patient wearing same type of clothing each time
What areas should deep palpation not be used
Areas the pose a risk to patient like an enlarged spleen or inflamed appendix
