week 5 Flashcards
steps to take oral temp
- talk to the patient let them know what you are going to do/ask for consent and perform hand hygiene
- open mouth
- place thermometer under tongue
- have patient hold thermometer between lips (not biting)
- take the temp and tell the patient their temp
- perform hand hygiene
steps to take radial pulse/respiration
- before pulse is taken…ask permission to touch
- perform hand hygiene and inform client that itll take about a minute to do assessment
- have patient sit and have their back flat against the chair and feet flat on the ground, place hand face up on the table
- place my fingers along radial bone at the flexor aspect
- assess for 30 secs for regular pulse and 60 secs if irregular pulse noting the rate, rhythm and force
- then assess respiration rate (rise and fall of chest) 30 secs= regular respiratory rate 60 secs=irreg
- tell client their pulse rate and rhythm…and if they are in normal range or not
steps to take apical pulse (adult)
- ask for permission to touch
- clean hands and wash stethoscope
- expose the left side of chest
- palpate the suprasternal notch
- move into the 5th intercostal space (in the midclavicular line)
- place stethoscope on the chest and listen to see if heart is regular (30 secs) if irreg (60 secs)
- tell client pulse rate and rhythm and say if they are in normal range or not
- regown client
- clean hands
steps for apical pulse for kids
same process but at the 4th intercostal space
steps for oxygen saturation
- clean hands and ask for consent and provide timeline for assessment
- place onto index finger
- take radial pulse for 30 secs and have them not talk
- tell radial pulse and O2 saturation
- clean hands
steps to take blood pressure
- clean hands
- have them put arm on table, palm face up, back against chair, feet on ground
- ask for consent to touch
- palpate brachial pulse
- place the cuff ontop of brachial artery
- determine max pressure inflation…can palpate either brachial or radial pulse
- close valve and inflate cuff quickly until i cant feel a pulse (then go 30milimiters of mercury past it)
- then quickly deflate cuff
- let arm reprofuse for about 15 secs and clean the stethoscope now can take BP
- put bell of stethoscope over brachial artery
- inflate cuff to max pressure inflation, slowly open valve, the first is systolic and last is diastolic and then deflate cuff
- tell client blood pressure
- clean hands
objective assessment techniques
-inspection
- palpation
- percussion
-auscultation
(done in that order)
technical skills and knowledge base
for inspection-what are you doing, what do you use
- watching closely
-comparing symmetry of the client
-sue good lighting - ensure adequate patient exposure
-otoscope, ophthalmoscope, specula(vaginal, nasal), penlight
palpation-what is it, what do you do
-touch points noted during inspection
-slow and systematic
- light vs deep palpation
- intermittent pressure
- bimanual palpation
what characteristics are assessed by palpation
- texture
- temp
- moisture
- organ size and location
- swelling
- vibration or pulsation
- rigidity or spasticity
- crepitation
-presence of lumps or masses - presence of tenderness or pain
palpation techniques
Fingertips-tactile discrimination ex skin texture, swelling, pulsation and finding lumps
Grasping action of fingers and thumb-position, shape and consistancy of an organ or mass
Back of hand and fingers- for temp
Base of fingers (metacarpophalangeal joints) or ulnar surface of hand-for vibrations
percussion-what is it, why do it and types
-tapping skin with short, sharp strokes to assess underlaying structures
- the vibration and sounds show location, size and density of underlaying organ
-direct percussion: striking hand contacts body wall directly
-indirect percussion: stationary hand, striking hand
for the info obtained from percussion(characteristics and what is noted)
characteristics:
- resonant
- hyperresonant
- tympany
- dull
- flat
note:
- amplitude
-pitch
- quality
- duration
auscultation-what it is and what do you use
-sense of hearing for detecting sounds produced by heart, blood vessels, lungs and abdomen
- uses stethoscope (diaphragm and bell endpieces)
what should the setting in the context of care be like and where
-patient’s home, clinic or hospital
-examination room: warm, comfy, quiet, private, well lit
- examination table: both sides of body are easily accessible
