Week #1 Concept Review Flashcards
Techniques: Skin, Hair, and Nails
What are the four basic techniques of physical assessment?
Inspection, Percussion, Palpation, and Auscultation
What technique is used initially in any physical assessment?
Inspection technique
What is the tool used for auscultation? What are the diaphragm and the bell used for?
A stethoscope, the diaphragm is used for high-pitched sounds that includes the lungs, the bell is used for low pitched sounds like Bruits and Cardiac Murmurs
What tools are used to assess during percussion? Name two-techniques and when they are used?
The use of the middle fingertips of the dominant hand, may be direct or indirect. Indirect assesses the lung tissue. Direct assesses; nasal congestion or sinus headache.
What is blunt percussion? Provide an example?
A type of percussion using the palm of the non-dominant hand flat over the CVA (Costovertebral Angle) of body area, the tapper is the closed fist of the dominant hand.
An example would be the assessment of a kidney injury when there is a hematoma noted at the CVA.
What tools are used during palpation? Provide an example of what can be assessed?
The finger pads and/ or metacarpophalangeal joint or ulnar part of the hand. An example, tactile fremitus (ask the patient to state 99, assess placements bilaterally).
What is the best technique to assess the lymph nodes?
Gentle circular motions
What is the best technique to assess Skin Turgor?
Pinching below the clavicles & below the wrist bilaterally
What is the best assessment for jaundice in dark skinned individuals?
Inspection of the lips, oral mucosa, sclera, conjunctiva, and soles of palms/ feet.
Why wash hands before and after every physical client intervention?
To protect examiner and client against the spread of infection.
Name the three skin layers and the second layers components
The top layer is the epidermis, and the second layer is the dermis. the dermis contains nerves, blood vessels, hair follicles. The third layer is the subcutaneous layer which is followed by muscle and bones.
What is a doppler?
An instrument used to assess pulses when pulses cannot be palpated.
What is a wood lamp?
An instrument used to assess for fungal infection of the skin
What is a skinfold caliper?
An instrument used to measure thickness subcutaneous tissue.
What is a stadiometer?
An instrument used to measure height
What is a goniometer?
An instrument used to measure joint extension and flexion
Describe a stage 1 decubitus ulcer
First layer of skin intact, erythematous lesion & non-blanchable
Describe a Stage II Decubitus Ulcer
A lesion involving 2 layers of tissue, bleeding is observed with partial thickness loss
Describe a Stage III Decubitus Ulcer
Lesion involving 3 layers of tissues- epidermis, dermis, and subcutaneous tissue. Full-thickness loss, slough can be present.
Describe a Stage IV Decubitus Ulcer
A lesion involving 4 layers of tissue- epidermis, dermis, and subcutaneous tissue and muscle and bones. Full thickness loss, eschar is present or dead tissue
When a client suddenly refuses your assessment or exam, what should you do as a Nurse?
Document what was done and what was refused by the client.
How is “grading of skin edema” performed?
Press around bony prominences of the body with your third finger pads of both hands. Grade zero- no edema. 1+=2 MM, 2+= 4 MM, 3+= 6 MM, 4+= 8 MM
Where are the popliteal pulses located?
located behind the knees medially
Where is the radial pulse located?
Located laterally when hands are in supine position at the wrists in line with the thumbs.
Where are the ulnar pulses located?
Located medially when the hands are supine position at the wrist in line with the little fingers
Where are the brachial pulses located?
The brachial pulses are located at the antecubital area of the arms
Where are the femoral pulses located?
The femoral pulses are located at the inguinal areas
