Class 11: Assessment Flashcards
inspection
use of vision and hearing to distinguish normal from abnormal findings. provides valuable clues about a pt health status. Nurses need experience to recognize normal variations among pt of different age groups
important points to remember for inspection
- make sure you have adequate lighting
- position so all body parts can be viewed
- compare with other side of body
- do not rush
palpation
use of hands to touch body parts to make. sensitive assessments. used to examine all accessible parts of the body
percussion
tapping the body with the fingertips to produce a vibration that travels through body tissues
auscultation
involves listening to sounds the body make to detect variations from normal usually through stethoscope
capillary refill
applying pressure to the nail bed and observing what happens after. will go white then should return to pink within seconds. if this doesn’t happen it indicates circulatory insufficiency
cyanosis
bluish discolouration around lips and nail beds
edema
areas of skin become swollen or edematous from a build up of fluid in the tissues
pallor
paleness may be caused by reduced blood flow and oxygen
pruritis
itching of skin, accompanies most rashes
dyspnea
difficult or uncomfortable breathing
orthopnea
abnormal condition where the person must use multiple pillows when lying down or must sit with arms elevated and leaning forward to breathe
hypoxia
inadequate tissue oxygenation at the cellular level
CWMS
colour, warmth, movement, sensation
diaphoretic
sweating
ecchymosis
discolouration of the skin resulting from bleeding underneath (bruising)
adventitious breath sounds
abnormal breath sounds
crackles
most common in dependent lobes; right and left lung bases. sounds during inspirations
wheezes
heard over all lung fields. high pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration
nebulization
process of adding moisture or medications to inspired air by mixing particles of varying size with the air
bowel sounds
abdomen is auscultated, normal bowel sounds occur every 5 to 15 seconds and last from 1 second to several
anterior
front of body
dorsal
back of body
inferior
lower parts of body
superior
upper parts of body
lateral
surfaces farther away from medial plane
medial
surfaces closer to the medial plane
proximal
located nearest centre of body
distal
away from the centre body
ipsilateral
on the same side
contralateral
on the opposite side
superficial
surface wound
deep
deeper wound
interior
within
exterior
outside
quick priority
ABC, input/output, pain, safety, LOO, LOC, focused assessment (chief complaint), comprehensive (head to toe)
level of consciousness
- confused
- delirious
- somnolent (sleepy can’t open their eyes)
- obtunded (decreased alertness)
- stuporous (very little activity - waken with stimulation)
- comatose (not responding even with yelling)
level of orientation
person, place, time, person (state their name), place (state where they are), time(state the date). can use less specific things if too hard
comprehensive assessment
- consider all of the patients needs in order to identify actual or potential problems
- general survey
- vital signs
- height and weight
- assessment of all organ and body systems including psychosocial domains
focused assessment
- modified assessment using knowledge of the patients history and presenting problem (chief complaint)
- may yield info that will require assessment of other systems related to chief complaint
baseline
pattern of findings identified when client first assessed
physical examination
inspection, auscultation, palpation, percussion
what part of a physical examination is not in an LPN score
percussion
symptom assessment
OPQRSTUV O: onset P: provoking/palliating Q: quality R: region/radiation S: severity T: timing (does it happen regularly?) U: understanding (what do you think is happening?) V: values (what do you want to do about this?)
palliating
what makes it feel better
chest assessment
assessing for crackles
wheezing
rhonchi
pleural rub
crackles
sounds like rice krispies
wheezes
whistling
rhonchi
sounds like snoring (rumbling)
pleural friction rub
sounds like walking on snow
lung field assessment
- back and forth on both sides
- sit upright/ lean forward if they can
- breath normally
- look at skin colour
tactile fremitus
vibration
abdominal assessment
-can be laying down (preferred, knees bent, lower legs apart)
-look for distension
1. inspect
2. auscultate - direction the bowels move (listen for quality and presence)
3. palpate
4. percussion
BS x4
NO BOWEL SOUNDS VERY CONCERNING
-listen for a full minute in each quadrant before saying there’s no bowel sounds (RLQ-RUQ-LUQ-LLQ)
peripheral vascular assessment
- CWMS
- pain/tenderness
- capillary refill (less than 2 seconds)
- movement of extremities
- compare one side of the body to the ohter
- pulse deficit
- clubbing
- edema
edema scale
0+: no pitting edema
1+: mild pitting edema. 2 mm depression that disappears rapidly
2+: moderate pitting edema. 4 mm depression disappears in 10-15 sec.
3+: moderately severe pitting edema. 6 mm depression that may last more than 1 min.
4+: severe pitting edema. 8 mm depression that can last more than 2 mins
