Physical Assessment Part 1 Flashcards
1
Q
Types of Nursing Assessment
A
- Admission Assessment (all the details)
- Shift Assessment (from day to day)
- Focused Assessment (on one specific area of the patient)
2
Q
Organization of Nursing Assessment
A
- head-to-toe
- systems
- concepts
chose which works best for you!
3
Q
Why do we assess patients?
A
- assess functional ability, nursing history
- establish nursing diagnoses and plan of care
- to assess progress and outcomes
- make clinical judgments
- identify areas for teaching
- communicate the client’s health status
4
Q
How do we assess patients?
A
- types: subjective (symptoms), objective (signs)
- sources: client, records, family and other health care providers
- collection: observation, interviewing, examining, reading
5
Q
What is your most important tool?
A
your senses: smell, taste, hearing, touch, and sight
6
Q
Tools to use during assessment
A
- non-sterile gloves
- stethoscope
- pen light
- pen & paper
- bandage scissors
- 2X2 gauze
- tongue blade
- Doppler
- conducting gel
- alcohol pads
- V/S equipment
- safety pin or needle
- tape measure
7
Q
Stethoscopes
A
- ear piece should fit snuggly in ear
- tubing should be between 12-18 inches
- chest piece should fit size of patient
8
Q
Diaphragm
A
- detects high-pitched sounds like breath sounds, normal heart sounds, bowel sounds
- press firmly against skin
9
Q
Bell
A
- detects low pitched sounds like abnormal heart sounds
- lay lightly on skin
10
Q
Doppler
A
- ultrasonic stethoscopes that detect blood flow rather than amplify sound
- need transmission gel on skin
11
Q
Inspection
A
- visual observation to determine health status
- throughout entire physical
- size, shape, color, symmetry, position, abnormality
12
Q
Palpation
A
- determine: position, size, fluid, mass, movement, compressibility, pain, vibration, temperature
- use: palmer surface of fingers and pads, ulnar surface of hand and fingers, dorsal surface of hands
- always have warm and clean hands, fingernails should be short
- palpate tender areas last (do the easy things first)
- chat while palpating and watch
- wear gloves if necessary
- use two hands when palpating light (1cm) then deep (4cm)
13
Q
Auscultation
A
- listen for sounds produced by body
- should be done in quiet place
- place stethoscope on bare skin
- target and isolate each sound
- identify all the characteristics of each sound
14
Q
Duration (Auscultation Descriptive Terms)
A
long, short, continuous, interrupted
15
Q
Pitch (Auscultation Descriptive Terms)
A
high or low
