Term
| Collecting Objective Data |
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Definition
*Data collected by the nurse directly
*Physical Exam- Head-to-toe
*Gather all equipment prior to start of exam |
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Term
| Physical Examination Preparation |
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Definition
*Comfortable, warm temperature
*Private area free of interuption
*Quiet area with adequate lighting
*Firm examination table or bed
*Bedside table/tray to hold equipment |
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Term
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Definition
*Assume that every person is potentially infected or colonized with an organism that can be transmitted
*Apply the following infection control practices:
1. Hand Hygiene
2. Gloves
3. Mask, eye protection, face shield
4. Gown
5. Patient care equipment/ Patient placement
6. Linen; occupational health and blood borne pathogens |
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Term
| Client Approach and Preparation |
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Definition
*Establish nurse-client relationship
*Explain the procedure and the physical assessment that will follow, describing the steps of the examination
*Respect client's requests and desires
*Explain the importance of the examination
*Leave room while client changes clothes
*Provide necessary container in case of sample
*Begin exam with less-intrusive procedures
*Explain procedures being performed
*Explain to client why position changes are necessary |
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Term
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Definition
*Sitting Position
*Supine Position
*Dorsal Recumbent
*Sim's Position
*Standing Position
*Prone Position
*Knee-chest Position
*Lithotomy Position |
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Term
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Definition
| Sit upright on exam table/bed |
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Term
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Definition
| Lying down with legs together[image] |
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Term
| Dorsal Recumbent Position |
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Definition
| Lays down on table, knees bent, legs separated, and feet flat on the table (May be more comfortable for patients with back pain)[image] |
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Term
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Definition
| Patient lays on side, with lower arm placed behind the body and the upper arm flexed at the shoulder. The lower leg is slightly flexed at a sharper angle and pulled forward [image] |
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Term
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Definition
| Stands still in a normal, comfortable, resting posture |
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Term
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Definition
| Patient lies down on the abdomen with the had to the side- used to assess back and hip joints[image] |
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Term
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Definition
| *Kneels on table/bed with the weight of the body supported by the chest and knees. A 90 degree angle should exist between the body and the hips[image] |
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Term
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Definition
| Patient lies on back with the hips at the edge of the table and the feet supported in stirrups[image] |
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Term
| Four Components of the Physical Exam |
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Definition
*Inspection
*Palpation
*Percussion
*Auscultation |
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Term
| Physical Examination: Inspection |
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Definition
*Inspection uses all of the sense: vision, smell, and hearing
*Begins the moment you meet your patient and is ongoing
*Inspection is ALWAYS first in the examination process- due to all others may alter appearance of what is being inspected
*Guidlines
-Room at comfortable temperature
-Good lighting
-Look and observe before touching
-Completely expose part being examined
-Note characteristics (color, size, location, symmetry, odors, sounds)
-Compare apperances (symmetry) |
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Term
| Physical Examination: Palpation |
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Definition
*Consists of using parts of the hand to touch and feel the following characteristics:
-Texture (Smooth/rough)
-Temperature/Moisture
-Mobility (fixed.moveable/still/vibrating)
-Consistency (Soft/hard/fluid filled)
-Strength of pulses (Strong/ medium/large)
-Shape (Well defined/irregular)
-Degree of tenderness |
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Term
| Parts of the Hand Used for Palpation |
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Definition
*Finger Pads- sensitive to fine discrimination, pulses, texture, size, crepitus
*Palmar Surface- Vibrations, thrills, fremitus
*Dorsal Surface- Temperature |
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Term
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Definition
*Light- Place dominant hand lightly on surface of the skin of the patient
*Moderate- Depress the skim 1-2 cm with dominant hand and use circular motion to feel body organs/masses
*Deep- Dominant hand on the skin and non-dominant hand on top of your dominant hand- depress 2.5-5 cm to feel very deep organs
*Bimanual- Using two hands, placing one on each side of the body part-one hand to apply pressure and the other hand to feel structure (breast exam) |
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Term
| Physical Examination: Percussion |
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Definition
*Involves tapping on body part to produce sounds waves
*Sounds waves or vibrations enable examiner to assess underlying structures
*Purposes:
-Eliciting pain
-Determining location, size, and shape
-Determining density
-Detecting abnormal masses
-Eliciting reflexes |
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Term
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Definition
*Direct Percussion- Direct tapping of a body part with one or two fingers to elicit possible tenderness (tenderness over the sinuses)
*Blunt Percussion- Used to detect tenderness over organs- place one hand flat on surface and use the first of other hand to strike the back of the hand
*Indirect or Mediate Percussion- Most commonly used. Produces sound or tone that varies with density of underlying structures |
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Term
| Physical Examination- Auscultation |
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Definition
*Type of Assessment technique that requires the use of a stethoscope
*Can hear sounds not audible to ear
*Sounds include: heart sounds, lung sounds, blood flow through vascular system, bowel sounds
*Sounds classified according to:
- Intensity (loud/soft)
-Pitch (High/low)
-Duration (Length)
-Quality (musical, crackling, raspy)
*Technique:
-Eliminate distracting noise
-Expose the body part (NEVER through clothing)
-Diaphragm of stethoscope for high-pitched sounds (heart, bowel, breath)
-Bell of stethoscope for low-pitched sounds (abnormal heart, bruits)
-Place earpieces into outer ear canal |
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Term
| Resonance with Percussion |
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Definition
*Heard over part air and part solid
*Intensity-Loud
*Pitch-Low
*Length-Long
*Quality-Hollow
*Heard over normal lung |
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Term
| Hyper-resonance with Percussion |
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Definition
*Heard over mostly air
*Intensity-Very loud
Pitch-Low
Length- Long
Quality- Booming
*Heard over lung with emphysema |
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Term
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Definition
*Heard over mostly air
*Intensity- Loud
*Pitch- High
*Length- Moderate
*Quality- Drum-like
*Puffed out cheek, gastric bubble |
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Term
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Definition
*Heard over more solid tissue
*Intensity- Medium
*Pitch- Medium
*Length- Moderate
*Quality- Thud-like
* Heard over Diaphragm, Plural effusion, Liver |
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Term
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Definition
*Heard over very dense tissue
*Intensity- Soft
*Pitch- High
*Length- Short
*Quality- Flat
*Muscle, bone, sternum, thigh |
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Term
| Resonance with Percussion |
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Definition
*Heard over part air and part solid
*Intensity-Loud
*Pitch-Low
*Length-Long
*Quality-Hollow
*Heard over normal lung |
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Term
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Definition
| Measures skinfold thickness of subcutaneous tissue[image] |
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Term
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Definition
| Measures mid-arm circumference. |
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Term
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Definition
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Term
| Braden Scale for Predicting Pressure Sore Risk |
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Definition
| Predicts Pressure Sore Risk |
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Term
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Definition
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Term
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Definition
| Views the red reflex and examines[image] the retina of the eye |
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Term
| Otoscope to view the ear canal and tympanic membrane |
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Definition
*Views the ear canal and tympanic membrane
*With wide-tip attachment to view the internal nose
[image] |
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Term
| Doppler Ultrasound Device and Conductivity Gel |
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Definition
| Detects pressure and weak pulses not easily heard with a stethoscope |
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