Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Health Assessment > Lecture 3 - Hand Hygiene, Assessment Techniques, and Vital Signs > Flashcards

Lecture 3 - Hand Hygiene, Assessment Techniques, and Vital Signs Flashcards

1
Q

What is the most effective way to decrease the transmission of disease?

A

Hand Hygiene

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the five situations where hand hygiene must be performed?

A
  1. Before initial contact
  2. Before aseptic procedures
  3. After body fluid exposure
  4. After contact
  5. After doffing gloves
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

In which order should the four basic physical assessment techniques be used?

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the definition of Inspection?

A

Concentrated watching. A visual evaluation of the patent as a whole, as well individual systems.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the steps of performing inspection?

A
  1. Start general, then localize as necessary
  2. Compare bilaterally for symmetry
  3. Properly visualize anatomy through use of lighting, adequate exposure, and PRN instruments.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the definition of palpation?

A

Physical contact with or manipulation of the target structure.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is crepitation?

A

Crackling or rattling due to presence of air bubbles

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is spacicity?

A

Abnormal muscle tone of stiffness, more pliable than rigidity.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Which part of the hand is best to palpate and discriminate against fine tactile details?

A

The fingertips

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How would one palpate for position, shape, or consistency?

A

By grasping with fingers and thumb.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What part of the hand is best for palpating temperature?

A

The dorsal aspect of hands or fingers.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Which part of the hand is best for palpating vibrations

A

The knuckles, metacarpal phalangeal joints.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are the steps of performing palpation?

A
  1. Select anatomy of focus
  2. Start superficially, then move deeper. When palpating deeply, alternate between pushing and letting go, to reduce discomfort of patient.
  3. Use one or two hands, as needed.
  4. Areas of tenderness are done last.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

When might two hands be necessary for palpation?

A

To cup or enclose organs such as the kidneys, uterus, or adnexa.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

When should palpation be avoided?

A

When an abdominal aortic aneurism is suspected. In this situation, additional pressure may cause further damage.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is the definition of percussion?

A

Tapping skin to assess structures using sound.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the steps to performing palpation?

A
  1. Hyperextend non dominant middle finger and place on patient. This is the pleximeter, or stationary hand
  2. Strike finger twice with middle finger of dominant hand. This is the plexor, or striking hand.
  3. Repeat around area as necessary

(This is an example of indirect percussion)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

When might use of direct percussion be appropriate?

A

When assessing the thorax of an infant or the sinus of an adult.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

When performing percussion on a structure, what does it mean if it loud?

A

It is probably hollow or partially air filled.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

When performing percussion on a structure what does it mean if it is high pitched?

A

It is dense tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

When performing percussion on a structure, what does a long duration of sound indicate?

A

That the structure is air filled.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What notes of quality should be made when performing percussion?

A

Words like clear, hollow, booming, musical, muffled, or dull can be useful.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What are the five characteristics of percussion notes?

A
  1. Resonant
  2. Hyper-resonant
  3. Tympany
  4. Dull
  5. Flat
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Describe the qualities of a resonant percussive note. Where is this normal?

A

Medium-loud, low pitch, with a clear, hollow sound. Moderate duration.

Normal over lung tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Describe the qualities of a hyper-resonant percussive note. Where is this normal?

A

Loud with a very low pitch. Booming sound with long duration.

Normal over child’s lung. Abnormal in adult lungs, might indicate increased amount of air - such as with emphysema.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Describe the qualities of a Tympanic percussive note. Where is this normal?

A

Loud. high pitched, musical note. Sustained, very long duration.

Normal over air filled viscus, such as the stomach or intestine.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Describe the qualities of a dull percussive note. Where is this normal?

A

Soft, high pitched, with a muffled thud. Short duration.

Normal over dense organs, such as a liver or spleen.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Describe the qualities of a flat percussive note. Where is this normal?

A

Very soft, high pitched sound with absolute dullness and zero resonance at all. Very short in duration.

Heard when no air is present, such as over thigh muscles, bone, or a a tumor.

28
Q

The diaphragm of a stethoscope is better for hearing which kind of noises?

A

Higher pitched sounds, such as lung or bowel noises.

29
Q

The bell of a stethoscope is better for hearing which kind of noises?

A

Softer, low pitch sounds.

30
Q

What are the five main Vital Signs (and what are the additional two often not included in this list)?

A
  1. Temperature
  2. Pulse
  3. Respiratory Rate
  4. Pulse oximetry
  5. Blood pressure

Additionally included:
6. LoC
7. Pain

31
Q

When are vital signs taken?

A

In emergency situations, and as requested by physician in care plan.

32
Q

What is the normal set point for body temperature in celcius?

A

37.2°C

33
Q

How does body temperature fluctuate throughout the day?

A

Due the the diurnal cycle, temperature variation of between 1-1.5°C are normal throughout the day.

Temperature is highest in the afternoon, and lowest in the morning.

34
Q

How does a menstruating person’s temperature change with thier hormonal cycle?

A

Due to progesterone, temperature might increase 0.5-1°C during the luteal phase.

35
Q

How does age affect body temperature?

A

Temperature decreases with age, and is often lower in children who lose heat easier. Mean temperature of older adults is 36.2°C.

36
Q

How does stress affect body temperature?

A

Endogenous pyrogens secreted during periods of chronic stress increase overall body temperature.

37
Q

When should oral temperature not be taken?

A

When an individual is under five or otherwise unable to keep their lips sealed.
Additionally, wait to take temperature if they have just eaten/drank something hot or cold, or if they have just smoked.

38
Q

What is the normal oral temperature range?

A

35.8 - 37.3°

39
Q

What is the preferred site to take the temperature of an individual under five?

A

Axillary temperature.

40
Q

What is the normal axillary temperature range?

A

0.3 - 0.6°C lower than oral

41
Q

What is the preferred route of taking the temperature of a newborn or comatose patient?

A

Rectal temperature

42
Q

What is the normal range of rectal temperature?

A

0.4 - 0.5°C higher than oral

43
Q

What is the normal range for tympanic membrane temperature?

A

0.3 - 0.6° higher than oral

44
Q

What is the normal range of temporal artery temperature?

A

0.3 - 0.6°C lower than oral

*more susceptible for inaccurate measurement compared to other methods. Should only be used for ballpark measurements.

45
Q

What are some potential causes for hyperthermia?

A

Infection or tissue breakdown that might occur during myocardial infarction, trauma, or surgery. May also be due to tumor or a neurological disorder.

46
Q

What is therapeutic hypothermia? Why might it be used?

A

Gradually induced hypothermia. Might be done during time when blood is not oxygen saturated or when heart is not functioning properly to slow blood flow and protect neural tissue.

47
Q

How is pulse taken?

A

Use first three finger pads to count palpable blood rushing arteries.

If pulse is regular: (beats/30s) x2

If pulse is irregular: Count full 60s.

48
Q

From head to toe, list the eight places pulse can be taken.

A
  1. Temporal artery
  2. Common carotid artery
  3. Brachial artery
  4. Radial artery
  5. Femoral artery
  6. Popliteal artery
  7. Posterior tibial artery
  8. Dorsalis pedis artery
49
Q

When might the pulse be taken from the dorsalis pedis artery?

A

When checking for circulatory issues in the leg.

50
Q

Where should the pulse be taken in emergency situations?

A

From the common carotid or femoral artery.

51
Q

Which qualities are noted when taking a pulse?

A
  1. Rate
  2. Rhythm
  3. Force
  4. Equality
52
Q

What is a normal heart rate?

A

50 - 95 bpm

53
Q

How is force of a pulse described?

A

With the following grading scale:
3+ = full bounding
2+ = normal
1+ = weak, thready
0 = absent

54
Q

Where should pulse not be taken bilaterally?

A

From the common carotid arteries.

55
Q

What is sinus arrhythmia? When is it normal?

A

When heart rate accelerated during inspiration and returns to normal during expiration.

Normal in children and some adolescents.

56
Q

What is a normal range of respiration rate in an adult?

A

10-20 breaths/min

57
Q

What should be noted during an assessment of respiration?

A

Breath rate & quality (effort, sound, rhythm, depth)

58
Q

What should be noted when taking the respiratory rate of an older adult?

A

Older adults tend to have an increased respiratory rate - therefore, you must count for the full 60 seconds, even if breaths are regular.

59
Q

What is pulse oximetry?

A

A measure of the saturation of blood hemoglobin with O2 in peripheral capillaries

PsO2 = “Peripheral artery oxygen saturation”

60
Q

What are normal SpO2 readings? What are exceptions to this?

A

Normal range is anything higher than 95%.

Those with COPD will have lower values than most, this is normal for the individual.

61
Q

What kinds of things will affect the SpO2 reading accuracy?

A

Movement, cold hands, certain nail polishes, poor perfusion, thick skin and callouses.

62
Q

What are abnormal temperature readings?

A

Anything lower than 35°C or higher than 38°C

63
Q

What is Tangential Lighting? When is it most useful?

A

Light directed at an angle, best highlights pulsations and body contour. Preferred for inspection over perpendicular lighting.

64
Q

What does an otoscope do?

A

Funnels light into the ear canal and onto the tympanic membrane.

65
Q

What does an ophthalmoscope do?

A

Illuminates the internal eye structures and allows you to look through pupil at the fundus of the eye.

66
Q

What is the procedure when taking blood pressure of an adult?

A

BP should be taken after waiting at least 5 minutes into the assessment, and should be taken three times, each reading separated by two minutes. Discard the first reading, and average the other two.

67
Q

What is the auscultatory gap?

A

Silence for about 30-40mmHg after systolic pressure. Common those with hypertension, occurs in 5% of the population.

If undetected, systolic will be falsely low or diastolic will be falsely high.

Health Assessment (14 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions