WEEK 1 Flashcards
3 reasons why nurses carry out a physical assessment ?
- to obtain baseline data about a pt.
- to supplement, confirm or refute data obtained in the nursing history.
- obtain data that will help establish nursing diagnosis and plans of care.
What is the dorsal recumbent position?
Laying on back with knees up.
What is the lithotomy position?
Laying on back with feet supported up in stirrups.
What is sims position?
Side-lying position with the lowermost arm behind back and leg flexed up at hip.
What is light (superficial) palpation?
Always done first
Done with 1 hand
Pressing gently, skin only slightly depressed
What is deep palpation?
Done with 2 hands
Top hand applies pressure and bottom hand relaxed
What is direct percussion?
Area of body is struck directly with 2/3/4 fingers.
Stokes are rapid and movement is from the wrist.
Useful for percussion adult sinuses.
What is indirect percussion ?
Middle finger if non dominant hand is placed firmly on pt skin.
Dominant middle finger strikes non dominant middle finger.
Blows should be rapid.
What are the 5 sounds of percussion ?
Flatness Dullness Resonance Hyperresonance Tympany
What does ‘flatness’ percussion sound like?
Extremely dull sound produced by very dense tissue such as muscle or bone
What does ‘dullness’ percussion sound like ?
Thud like sound produced by dense tissue such as liver, spleen or heart
What does ‘resonance’ percussion sound like?
Hollow sound such as lungs filled with air
What does ‘hyperresonance’ percussion sound like ?
Described as booming sound
What does ‘tympany’ percussion sound like ?
Musical or drum like sound
E.g. Stomach filled with air
What is percussion sound described by ?
SIPDQ
Sound Intensity Pitch Duration Quality
