intro to physical assessment Flashcards
what is the purpose of physical assessments
to gather baseline data, supplement; confirm; or refute previous data, confirm and identify nursing diagnosis, evaluate physiological outcomes of care
the 2 types of data
subjective, objective
the 2 sources of data
primary, secondary
3 phases of the interview process
Orientation, working, termination
4 types of physical assessment
comprehensive, focused, system specific, ongoing
what are the elements of the history assessment
baseline history, problem based history
what are the elements of the examination assessment
vital signs, inspection, auscultation, palpation
what are the 4 used techniques for assessment
inspection, palpation, auscultation, olfaction
what sense is not used in assessments
taste
what are 3 things to remember when doing an inspection
have good lighting, drape or cover parts not being examined for privacy, use additional lighting devices when needed
what are you observing for when doing an inspection
color, shape/symmetry, movement, position
light palpation
1 cm or 1/2 in deep
deep palpation
4 cm or 2 in deep
what are 8 things you are observing when doing a palpation assessment
texture, resistance, resilience, mobility, temperature, thickness, shape, moisture
frequency
of oscillations per second generated by a vibrating object
loudness
amplitude of a sound waves
quality
descriptive
duration
length of time that sounds lasts
where do you place the stethoscope
directly on the skin
bell of stethoscope
best for low pitched sounds
diaphragm of stethoscope
best for high pitched sounds
what do you look for in an olfactory assessment
abnormal vs normal smells
what are 3 special considerations for age?
adjust position, allow more time, allow more space
what do you begin the assessment with
a general survey
4 signs of abuse
Inconsistency, bruises/lacerations/burns/bites, x-ray shows various stages of healing, behavioral issues
