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NUR211 > Module 3 part 2 > Flashcards

Module 3 part 2 Flashcards

Ch 5 assessment techniques

1
Q

How long to wash hands

A

20 seconds

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2
Q

How much alcohol in alcohol based rub for hands

A

60 to 95%

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3
Q

My 5 Moments for Hand Hygiene

A
  1. Before touching a patient.
  2. Before clean/aseptic procedures.
  3. After body fluid exposure/risk.
  4. After touching a patient.
  5. After touching patient surroundings.
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4
Q

What are contact precautions

A
  • known or suspected infections w/ contact transmission
  • gloves, gown
    *gloves gown before entering room
    *discard gloves gown before exiting room
  • disinfect common use equipment before use for next patient
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5
Q

Droplet precautions

A
  • Droplets are the “bigger” particle
  • mask before entering
    *no gloves
    Limit transport and movement of patients outside of the room to only medically necessary purposes. **If transport or movement outside of the room is necessary, instruct patient the to wear a mask **and follow respiratory hygiene/cough etiquette.
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6
Q

Airborne precautions

A
  • small particle that can fly through your regular mask in air
  • airborne infection isolation room
  • fit tested NIOSH N 95 mask
    *no gloves
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7
Q

What viruses are airborne

A
  • chickenpox, covid-19
  • TB
  • measles
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8
Q

Where do you wash your hands?

A

In front of the patient.

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9
Q

Whats a HAI?

A
  • Healthcare associated infections
  • a patient is recieving care for a UTI for example, and then contracts the flu from the healthcare provider who didn’t wash hands.
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10
Q

Whats a concern about latex gloves?

A

The patient could be allergic to latex

The equipment could have latex.

make sure you check their allergies

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11
Q

CDC guidelines in 2020 for covid

A
  • 6 feet away
  • wash hands 20 seconds or sanitizer w 60%
  • Clean and disinfect routinely high-touch surfaces (i.e., electronics, doorknobs, light switches, tables).
  • Wear a face covering in public settings and when around people who don’t live in your household, especially when other social distancing measures are difficult to maintain
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12
Q

What side is best for assessing the patient

A

the right side of the patient

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13
Q

Sequence of assessment

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation

unless abdomen

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14
Q

What is direct inspection?

A

observing and inspecting a specific area or the whole individual.

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15
Q

what is indirect inspection?

A

using specific equipment to improve your visualization of an area (i.e., ophthalmoscope to look at the internal structures of the eyes).

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16
Q

What senses does inspection use?

A

Inspection requires the use of three of your senses:
1. Seeing
2. Hearing
3. Smelling (body odor)

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17
Q

Fluorescent lights vs normal lights?

A

normal.

florescent lights change skin color.

18
Q

What PPE while palpating?

A

Gloves
* gloves and eyewear IF palpating open wound area, tongue, mouth, mucous membranes

19
Q

How to assess temperature?

A

Dorsal surface of the hand (back of hand)

20
Q

Finger pads assess what?

A

texture, shape, consistency, pulses, and crepitus

21
Q

What is used to assess fremitus (vibe thru body) and thrills (vibration over chest wall)

A

Ulnar surface or ball of the hand

22
Q

How deep do you press down for light palpation and what is the motion

A

1 cm or 1/2 inch
light circular motions
USING FINGER PADS

23
Q

How is deep palpation done?

A
  • one OR two hands
  • dominant hand on top
  • press 5 cm or 2 inches
24
Q

What are you feeling for with deep palpation vs light palpation

A

light:
Texture
Masses Moisture Pulsations Temperature Tenderness

deep:
Organ size and location
Masses
Tenderness

25
Q

What are 3 types of percussion?

A

direct, indirect, indirect fist (blunt)

26
Q

What PPE for direct percussion?

A

gloves

additional PPE if needed

27
Q

What are you assessing for using direct percussion and what is it

A
  • directly tapping the patient (not thru DIP)
  • one to two fingertips
  • size, consistency and borders of body organs
  • see if fluid is present
28
Q

Direct percussion

soft tones?
moderate tones?
loud tones?

A
  • Soft tones are heard over solid tissue (vibration absorbed)
  • Moderate tones are heard over fluid-filled areas (hearing someone yell when you are underwater)
  • Loud tones are heard over air-filled spaces (vibration carries through air like speakers in a concert)
29
Q

Quality of sound

Tympany?
Dullness?
Resonance?
Hyperresonance?
Flatness?

A
  • Tympany is heard over abdominal areas that may be filled
    with abdominal gas or air-filled structures. (concert)
  • Dullness is heard over solid organs, fluid collection, or areas
    of consolidation (such as a tumor or mass).
  • Resonance is heard over normal lung fields. (lungs are resonant)
  • Hyperresonance is heard over air-filled spaces such as lung
    fields in a patient with emphysema. (air sacs are bigger than normal)
  • Flatness is heard over increased tissue density such as bones.
30
Q

Again, what is flatness, and what is dullness?

A

Dullness is solid organs, fluid, or consolidation of a mass

Flatness is increased density like bones

31
Q

pitch and quality of:
Tympathy
Dullness
Resonance
Hyperresonance
Flatness

A
  • Tympany: high pitch, drumlike
  • Dullness: medium pitch, thudlike
  • Resonance: low pitch, hollow (normal lung sounds)
  • hyperresonance: pitch low, booming
  • flatness: high pitch, dull quality
31
Q

What is indirect percussion and what is it used for?

& what equipment?

A

To assess the size, consistency, and borders of body organs, and the presence or absence of fluid in body areas

Equipment: Gloves, additional PPE (if needed)

middle finger of left hand is called the pleximeter. it is struck at the DIP by the right hand’s middle finger (the plexor).

32
Q

What is indirect fist percussion
(blunt percussion)

PPE needed

and procedure?

A

To assess organ tenderness (kidneys usually)

gloves

  1. Explain the technique to your patient.
  2. Expose only the area that you will be percussing.
  3. Gently lay your nondominant hand over the area to be assessed.
  4. Make a fist with your dominant hand.
  5. Using the ulnar surface of your closed fist, firmly **thump the
    dorsum of the nondominant hand **
  6. Ask the patient if he or she experiences any discomfort.
33
Q

Auscultation is used to assess?
What equipment and why?

A

Auscultation is used to listen to and assess cardiovascular, respiratory, gastrointestinal, and peripheral vascular sounds produced by the body.

If you don’t hear the peripheral blood flow with a stethoscope, use a doppler ultrasonic blood flow detector

34
Q

Two types of auscultation and explain what they mean.

A

direct and indirect

direct is WITHOUT a stethoscope. indirect is WITH a stethoscope (or other device like doppler).

35
Q

What are the measurements of auscultation?

A

Duration (length of time)
Intensity (loud or soft)
Pitch (high or low)
Quality (e.g., musical, blowing, bubbly)

36
Q

How long do you auscultate?

A

one full minute.

37
Q

What are the most common sounds that are heard during direct auscultation? How do you confirm the sound?

A

Most common sounds that can be heard without equipment are respiratory and gastrointestinal sounds. Always confirm sounds with a stethoscope to tell what it is.

38
Q

What can the bell and diaphragm hear?

A

The bell - low- pitched sounds (e.g., vascular sounds and heart murmurs);

the diaphragm- high- pitched sounds (e.g., respiratory sounds and bowel sounds).

39
Q

During indirect auscultation, what do you do if the patient has a lot of hair?

A
  • If the patient has much hair on the area to be auscultated, wet the hair with a warm washcloth to decrease the friction.
  • Concentrate and listen to the sounds.
  • When finished auscultating, clean off your stethoscope with an
  • alcohol swab (you would anyway)
40
Q

What is the idea with stethoscope cleaning between patients?

A

Stethoscopes may transmit infectious agents, which could result in healthcare-associated infections (HCAI)

41
Q

How do you clean your stethoscope

A

alcohol swabs, hydrogen peroxide wipes, and alcohol-based hand sanitizers, all work; if Clostridium difficile is suspected, a

bleach wipe should be used

do it while you do hand hygeine when entering room and before exiting room

NUR211 (12 decks)

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