Unit 2: Approach to clinical setting

Question 1

Proper Hand Washing Technique

Answer 1

• 15-20 seconds “happy birthday” twice

- luke warm water and antibacterial soap

Question 2

c-diff

Answer 2

smelly, painful, explosive diarrhea every 15 minutes

- can last 6-8 weeks in a health person

Question 3

Tools of physical assessment

Answer 3

insepction, palpation, percussion, auscultation

Question 4

Inspection

Answer 4

• 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)

Question 5

palpation

Answer 5

• 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)

Question 6

parts of hands for palpation

Answer 6

• 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

Question 7

Percussion

Answer 7

• 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

Question 8

indirect percussion

Answer 8

• use middle finger only
• tap twice and lift up
• you can use this to estimate the size of organs

Question 9

Auscultation

Answer 9

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,

Question 10

patient positioning

Answer 10

• 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)

Question 11

thermometers

Answer 11

electronic:
tympanic: ear - varied accuracy
temporal: uses in fared, highly accurate

Question 12

stethoscope

Answer 12

diaphragm: high pitched sounds, respiratory, bowel sounds, normal heart sounds
Bell: soft/low-pitched sounds - extra heart sounds, vascular sounds,

Question 13

sphygmomanometer

Answer 13

measures arterial blood pressure

Question 14

pulse ox

Answer 14

measures arterial oxygen saturation in blood

- % of hemoglobin that is binded to an oxygen molecule

Question 15

weight

Answer 15

daily weight certain patients:

• CHF patients (edema)
• gastric bypas (weight loss surgery)
• dialysis patients (urinary issues)
• infants with failure to thrive

Question 16

visual acuity and screening

Answer 16

snellen chart is a wall chart placed 20 ft from patient

- E chart is used for young children and on-english speaking patients

Question 17

otoscope

Answer 17

used to look at tyrannic membrane. sends small puffs of air to evaluate fluctuation of tympanic membrane in children

Question 18

penlight

Answer 18

• illuminate mouth or nose
• highlight a lesion
• evaluate pupillary constriction

Question 19

nasal speculum

Answer 19

used to inspect lower and middle turbinates of the nose.

Question 20

tuning fork

Answer 20

auditory screening and and vibratory sensation

Question 21

reflex hammer

Answer 21

used to test deep tendon reflexes “percussion hammer”

Question 22

doppler

Answer 22

usees ultrasonic waves to detect and amplify difficult-to-hear vascular sounds such as fetal heart sounds and peripheral pulses

Question 23

goniometer

Answer 23

degree of flexion and extension of joint

Question 24

monofilament

Answer 24

used to test lower extremity sensation

- small, flexible wirelike deice attached to handle NEURO

Question 25

transilluminator

Answer 25

used to differentiate characteristics of tissue, fluid, air in specific body cavity

Question 26

woods lamp

Answer 26

detects fungal infection of skin, detects corneal abrasions (with use of florescent dye)

Question 27

general inspection

Answer 27

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

Question 28

chachexia

Answer 28

very very thin and malnourished

Question 29

VITAL signs

Answer 29

``` weight Height temperature pulse respiratory rate Blood Pressure 02 saturation ```

Question 30

Weight

Answer 30

BMI: overweight = 25-30 obese = 30 - 34 morbidly obese = 35+ weight to hip ratio is important android obesity = around the middle synoid obesity = butt

Question 31

Temperature

Answer 31

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

Question 32

heart rate

Answer 32

``` grade/strength of pulse 0 - none 1 - weak/thready 2 - normal 3 - full & strong ``` most common pulse location is radial pulse

Question 33

pulse

Answer 33

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

Question 34

resp rate

Answer 34

make sure patient is unaware - check depth: deep, normal or shallow * normal breathing = even, quiet, and effortless when patient is sitting or laying down

Question 35

blood pressure

Answer 35

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

Question 36

Systolic BP

Answer 36

max pressure exerted on arteries when ventricles eject blood from heart contract

Question 37

diastolic BP

Answer 37

min amount of pressure exerted on vessels when ventricles relax

Question 38

BP measurements

Answer 38

- 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.

Question 39

thigh BP

Answer 39

take when arm pressure is contraindicated or abrnoamlly high (adolescents and young adults)

Question 40

physiologic factors that affect BP

Answer 40

* 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.

Question 41

commons erros in BP Measurements

Answer 41

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

Question 42

pain = 5th vital sign

Answer 42

wing-baker Faces pain field = kids

Question 43

Abnormal Body/Height Proportions

Answer 43

* 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

Question 44

nociceptive pain

Answer 44

- arises from somatic structures like bone, joint or muscle. results from activation of normal neural systems

Question 45

neuropathic pain

Answer 45

occurs because of abnormal processing of sensory input