Chapter 8: Assessment techniques (palpation) Flashcards
Order of physical assessment
inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion).
Focused Inspection
inspection phase
takes time and yields a surprising amount of information.
focused assessment
is significantly more than a “quick glance
best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms
dorsa (backs) of the hands and fingers
best for fine, tactile discrimination
Fingertips
Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient
palpation
what involves vision
inspection
assesses through the use of palpable vibrations and audible sounds
percussion
what uses the sense of hearing.
auscultation
initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.
Light palpation
use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa
Bimanual palpation
what yields a sound that depicts the location, size, and density of the underlying organ
Percussion
Turgor and texture are assessed with?
palpation
percussion,
the nurse should percuss two times over each location
percussion
The striking finger should be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the arm.
Percussion over relatively dense organs, such as the liver or spleen makes what sound
dull
requires good lighting, adequate exposure, and occasional use of certain instruments (otoscope, ophthalmoscope, penlight, nasal and vaginal specula) to enlarge your view
Inspection
what assess texture; temperature; moisture; organ location and size; and any swelling, vibration or pulsation, rigidity or spasticity (muscle tightness), crepitation, presence of lumps or masses, and presence of tenderness or pain.
Palpation
what part of arm Best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps
fingertips
what detects the position, shape, and consistency of an organ or mass
grasping action of the fingers and thumb
whats best detecting vibration
Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand
deep palpation
(as for abdominal contents), intermittent pressure is better than one long, continuous palpation.
Mapping out the location and size of an organ by exploring where the percussion note changes between the borders of an organ and its neighbors
percussion
Signaling the density (air, fluid, or solid) of a structure by a characteristic note
percussiion
