chap 3 Flashcards
objective data
nurse directly observes it
nurse needs basic knowledge of
- types/operation of equipment needed
- prep of setting, oneself, and client
- performance of 4 assessment techniques
4 assessment techniques
- inspection
- palpation
- percussion
- auscultation
physical exam prep
- comfortable, warm temp
- private area free from interruptions
- quiet area free of distractions
- adequate lighting
- firm exam table
- bedside table/tray
standard precautions
used in care of all patients regardless of their diagnosis/infection
-combines universal and body substance precautions
standard precautions guidelines
- wash hands before exam
- wash hands immediately after direct contact w/ blood
- always wear gloves if chance of contact w/ blood/body fluids
- change gloves between pt’s
most important reason for wearing gloves
prevent nurse’s hands from being a vehicle of transmission from one pt to another
client approach/prep
- est. nurse pt relationship
- respect client’s requests/desires
- leave room while pt changes
- provide necessary container
- begin exam w/ less intrusive
- explain procedure
- explain why position change is necessary
inspection
- using senses to observe normal/abnormal findings
- room temp is comfortable
- good lighting
- LOOK before TOUCH
- note characteristics
- compare appearance
note the following characteristics when inspecting
- color
- pattern
- size
- location
- consistency
- symmetry
- movement
- behavior
- odors
- sounds
what to look for when palpating
- texture (rough/smooth)
- temp
- moisture (dry/wet)
- mobility (fixed/movable/still/vibrating)
- consistency (soft/hard/fluid filled)
- strength of pulse (strong/weak/bounding/thready)
- size
- shape (well defined/irregular)
- degree of tenderness
types of palpation
- light
- moderate
- deep
- bimanual
light palpation
- place dominant hand lightly on surface of structure
- very little to no depression
- feel surface using a circular motion
- feel for pulses, tenderness, surface skin texture, moisture
moderate palpation
- depress skin surface 1-2 cm with dominant hand
- note size, consistency, and mobility of structures
deep palpation
- place dominant hand on skin surface and non-dominant hand to apply pressure
- depression 2.5-5 cm
- allows to feel deep organs/structures covered by thick muscle
bimanual palpation
requires use of both hands to envelop/capture body parts/organs
percussion
involves tapping body part to produce sound waves to assess structures
purposes of percussion
- eliciting pain: helps detect inflamed underlying structure
- determining location, size, shape
- detecting abnormal masses
- eliciting reflexes: deep tendon reflexes elicited using percussion hammer
types of percussion
direct, blunt, indirect/mediate
direct percussion
direct tapping to elicit possible tenderness
blunt percussion
used to detect tenderness over organs
indirect/mediate percussion
MOST COMMON, sound varies w/ density
sounds elicited by percussion
- resonance
- hyperresonance
- tympany
- dullness
- flatness
as density increases sound becomes
quieter
auscultation
listening with a stethoscope
tips for auscultation
- eliminate distracting noise
- expose the body part being auscultated
- diaphragm of stethoscope = high pitched sounds
- bell of stethoscope = low pitched sounds
correct use of stethoscope
- place earpieces into outer ear canal
- angle binaurals down toward nose
- warm diaphragm/bell before use
- explain what you are listening to/answer questions
- avoid listening through clothes
- clean stethoscope
