Unit 2: Approach to clinical setting Flashcards
Proper Hand Washing Technique
- 15-20 seconds “happy birthday” twice
- luke warm water and antibacterial soap
c-diff
smelly, painful, explosive diarrhea every 15 minutes
- can last 6-8 weeks in a health person
Tools of physical assessment
insepction, palpation, percussion, auscultation
Inspection
- visual exam of body including movement and posture. smell also
use of equipment may help: - penlight -eyes, dilation
- otoscope - ears, tempanic membrane
- ophthalmoscope - eyes, distribution of blood vessels, retina
- nasal speculum - open up nose and look
- vaginal speculum
- woods lamp (black light) for fungal infections or corneal abrasion)
palpation
- use of hands to feel texture, size, shape, consistency, location of certain parts, and identify painful or tender areas
- requires nurse to move into personal space
- gentle touch, warm hands, short nails
- Light and Deep (requires training, can rupture spleen or gallbladder)
parts of hands for palpation
- fingertips: skin texture, swelling (edema), pulsations, lumps
- fingers and thumb (grasping): shape, consistency of an organ or mass
- dorsal of hands and fingers: temperature
- base of fingers/ulnar surface of the hand: vibrations
Percussion
- yields characteristic vibration sounds
- determines density, location and size of underlying organs or to elicit DTRs
LUNGS = resonance = air
ABDOMEN = fluid/air = tympany
ORGAN/MASS = solid = dullness
BONE = dense = flat - hyperresonance = too much air (COPD)
Use percussion in two areas:
1: costal vertebral angle - back where ribs end - kidney stones, kidney infection
2: Sinuses: sinus infection
indirect percussion
- use middle finger only
- tap twice and lift up
- you can use this to estimate the size of organs
Auscultation
listen to sounds within the body with a stethoscope
- listen for sound characteristics: intensity, pitch, duration and quality
- DIAPHRAGM: high pitch noises (respirations, abdomen)
- Bell: Low pitch (heart,
patient positioning
- move no more than 4 times throughout exam. laying, sitting, standing, sitting
- lithotomy position - vaginal exam in stirrups
- trandelenburg - feet up higher than head (central line placement)
thermometers
electronic:
tympanic: ear - varied accuracy
temporal: uses in fared, highly accurate
stethoscope
diaphragm: high pitched sounds, respiratory, bowel sounds, normal heart sounds
Bell: soft/low-pitched sounds - extra heart sounds, vascular sounds,
sphygmomanometer
measures arterial blood pressure
pulse ox
measures arterial oxygen saturation in blood
- % of hemoglobin that is binded to an oxygen molecule
weight
daily weight certain patients:
- CHF patients (edema)
- gastric bypas (weight loss surgery)
- dialysis patients (urinary issues)
- infants with failure to thrive
visual acuity and screening
snellen chart is a wall chart placed 20 ft from patient
- E chart is used for young children and on-english speaking patients
otoscope
used to look at tyrannic membrane. sends small puffs of air to evaluate fluctuation of tympanic membrane in children
penlight
- illuminate mouth or nose
- highlight a lesion
- evaluate pupillary constriction
nasal speculum
used to inspect lower and middle turbinates of the nose.
tuning fork
auditory screening and and vibratory sensation
reflex hammer
used to test deep tendon reflexes “percussion hammer”
doppler
usees ultrasonic waves to detect and amplify difficult-to-hear vascular sounds such as fetal heart sounds and peripheral pulses
goniometer
degree of flexion and extension of joint
monofilament
used to test lower extremity sensation
- small, flexible wirelike deice attached to handle NEURO
transilluminator
used to differentiate characteristics of tissue, fluid, air in specific body cavity
woods lamp
detects fungal infection of skin, detects corneal abrasions (with use of florescent dye)
general inspection
begins the moment the nurse meets the patient
- physical appearance, hygiene, body structure and movement, emotional and mental status, behavior
- use this to guide your health assessment
- note: assistive divice for walking, happy/depressed, dressed appropriate for weather, wounds, hygiene
chachexia
very very thin and malnourished
VITAL signs
weight Height temperature pulse respiratory rate Blood Pressure 02 saturation
Weight
BMI: overweight = 25-30
obese = 30 - 34
morbidly obese = 35+
weight to hip ratio is important
android obesity = around the middle
synoid obesity = butt
Temperature
body temp is regulated by the hypothalamus
- heat gained through process of metabolism and exercise
- heat lost through satiation, convection, conduction, and evaporation
- temps = 96.4 - 99.1 (normal)
- avg. 98.6 = stable core temperature at which cellular metabolism is most efficient
ORAL: safe and relatively accurate. delay 10 minutes if patent ingested hot or cold liquids or smoked. under tongue to get the carotid artery temp
TYMPANIC & AUXILLARY & RECTAL
heart rate
grade/strength of pulse 0 - none 1 - weak/thready 2 - normal 3 - full & strong
most common pulse location is radial pulse
pulse
apical pulse = use stethoscope over heart and count sounds for 1 minute
- 5th intercostal space at the mid-clavicular line
- use stethoscope
- PMI = point of maximal impulse
carotid artery - one finger, one side at time. can cut off blood flow to brain. lowe 3rd of neck
resp rate
make sure patient is unaware
- check depth: deep, normal or shallow
- normal breathing = even, quiet, and effortless when patient is sitting or laying down
blood pressure
force of blood against arterial walls
- reflects relationship between cardiac output and peripheral resistance
- Cardiac output = volume of blood ejected from heart each minute
- peripheral vascular resistance = force that opposes flow of blood through vessels; narrow arteries = high resistance and high BP
- blood pressure is dependent on cardiac output, PVR, viscosity of blood, intravascular blood volume, and elasticity of vessel walls
Systolic BP
max pressure exerted on arteries when ventricles eject blood from heart contract
diastolic BP
min amount of pressure exerted on vessels when ventricles relax
BP measurements
- systolic/diastolic 120/80
- pulse pressure = diff between systolic and diastolic and normally ranges between 30 mmhg and 40mmhg
- orthostatic BP = series obtained when the patient is lying, sitting, and then standing
- Korotkoff sounds are blood flow sounds that healthcare providers observe while taking blood pressure with a sphygmomanometer over the brachial artery in the antecubital fossa. These sounds appear and disappear as the blood pressure cuff is inflated and deflated.
thigh BP
take when arm pressure is contraindicated or abrnoamlly high (adolescents and young adults)
physiologic factors that affect BP
- age: gradual rise through childhood and into adulthood
- gender: after puberty, females show a lower BP than makes. after menopause females have higher BP
- race: AA have higher BP than white.
- diurnal variations: daily cycle of peak and trough occurs. BP climbs high in late PM and declings early morning
- emotions: rises with fear, anger, and pain
- pain: rises with pain/stress
- personal habits: exercise, sedentary, nutrition, etc.
commons erros in BP Measurements
improper arm position: above heart = low, below heart = high
improper cuff size: too narrow = high, too loose = high
deflating cuff: too fast = ow cyst and high dis, too slow = high dis
pain = 5th vital sign
wing-baker Faces pain field = kids
Abnormal Body/Height Proportions
- hypopituitary dworfism: deficiency in growth hormone in childhood results in retardation of growth below 3rd percentile, delayed puberty, hypothyroidism, and adrenal insufficiency
- gigantism: excessive secretion of growth hormone by anterior pituitary resulting in overgrowth of entire body. increased height, weight and delayed sexual development
- achondroplastic dwarfism: genetic disorder in converting cartilate to bone results in normal trunk size, short arms and legs, short stature. large head with frontal bossing and misplace hypoplasia.
- anorexia nerovosa: psych disorder sever life-threatening weight loss
- acromegaly: excessive secretion of growth hormone in adulthood, after normal completion of body growth. causes overgrowth of bone in face, head, hands, and feet but no change in height.
- Marfan’s syndrome: connective tissue disorder. tall, thin stature, hyperflexible joints
- endogenous obesity/Cushing’s syndrome: ACTH excess by pituitary will stimulate adrenal cortex to secrete excess cortisol. weight gain and edema with central trunk and cervical obesity, round face, accompanied by muscle wasting, weakness, thin arms and legs
nociceptive pain
- arises from somatic structures like bone, joint or muscle. results from activation of normal neural systems
neuropathic pain
occurs because of abnormal processing of sensory input
