Intro to Physical Assessment and Vital Signs

Question 1

Physical Examination

Answer 1

Inspection - see person, 1st step
Palpatation - one hand, texture, warmth, mosisture, tenderness, pulsation
(two hand for deep palpation)
Percussion - tapping of middle finger on middle finger
Auscultation - stethoscope, ear piece towards nose, diaghprhram is for higher pitches, bell for lower sounds (murmurs)

Question 2

National Patients Safety Goals

Answer 2

Two patient identifiers

• full name
• DOB

Question 3

Infection Control

Answer 3

Wash hands with soap and water for 15 seconds
Wash hands if soiled
Frequency and type of soap 
Warm water 
PPE when messing with bodily fluids
Hand sanitizer can be used

Question 4

Age considerations

Answer 4

Establish rapport
Provide warm, safe, private setting
Organize the exam
Keep a steady pace
Simple language - no medical jargon
Give praise
Listen to what the patient is saying verbally and nonverbally

Question 5

Infant (birth to 1 year)

Answer 5

Parent hold as much as possible
Never leave unattended
Do not use head to toe approach
Do most invasive last

Question 6

Toddler

Answer 6

Same as infant
Instruct parents on comfort holds
Keep items out of reach
Use age-appropriate terms

Question 7

Preschooler (3-5 years)

Answer 7

Offer choices when able
Ask if child wants to sit on exam table or on parents lap
If appears resistant, do more invasive items first

Question 8

School age (6-10 or 12)

Answer 8

Child more advanced but NOT a small adult
Head to toe
Provide privacy and warmth
Usually wants parents

Question 9

Adolscence (10-19)

Answer 9

Keep clothes on if possible
Examine alone
Head to toe approach
Genitalia last

Question 10

Older adult

Answer 10

Head to toe
Rest periods
Minimize position changes
Slow down
Take time

Question 11

Temperature

Answer 11

96.8 to 100.4 F
Fever 100.4 or higher

Factors affecting
Age
Exercise
Hormone levels
Circadian rythym (normal changes)
Stress
Environment

Sites:
Mouth (oral)
Rectum (rectal)
Under arm (axillary)
Ear (tympanic)
Forehead (temporal)
Core
Documentation
results
site

Question 12

Peripheral Pulse Sites

Answer 12

Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Dorsalsis Pedis

Question 13

Pulse

Answer 13

Apical:
Auscultate
Most accurate
Cardiac medications
Newborn/pediatric

Radial:
Most common
Thumb side of wrist
Do not use your thumb

Question 14

Respirations

Answer 14

Do not let patients know you are counting
Rate = one full expiration and inspiration
Depth = labor vs unlabored
Rythm = regular vs irregular

Question 15

Normal

Answer 15

120 (systolic blood pressure the peak pressure, produced by the contracting)
80 (diastolic blood pressure - the pressure in your arterties when the ventricles are relaxed

Question 16

Hypotension and Orthostatic hypotension

Answer 16

systolic < 90 mmHG

position, lying, standing

Question 17

Hypertension

Answer 17

2 different visits, if elevated repeat in 10-15 minutes
Elevated BP = 120-129/<80 mmgHG
Stage 1 = 130-139/80-89 mmHg
Stage 2 = 140 or higher/90 or higher
Crisis > 180 mmHG/ >110 (120) mmHg

Question 18

Additional Techniques

Answer 18

Pulse Oximeter

Electronic Vital Sign Monitor

Question 19

Pain Rating

Answer 19

Wong-Baker Faces scale
0-10 pain scale
Use as the 5th vital sign
Use an appropriate scale

Question 20

Sites

Answer 20

Upper arm
Wrist
Thigh
Ankle

Do Not Use if Possible

• IV site
• Lymph node removal
• Dialysis fistula or shunt

Question 21

Factors that influence BP

Answer 21

Age
Gender
Ethnicity and Genetics
Stress
Daily variations
Medications
Activity and Weight
Smoking