Term
FIVE basic assessment techniques |
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Definition
a. inspection, palpitation, percussion, auscultation, and olfaction) |
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Term
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Definition
a. visual examination of body parts or areas
i. Experienced nurse will make multiple observations, almost simultaneously, while becoming very perceptive of abnormalities
ii. always pay attention to the patient, watch all movements
iii. inspect carefully the body part in which you are examining
iv. requires good lighting and full exposure of body parts
v. size, shape, color, symmetry, position, and the presence of abnormalities
vi. inspect each area and compare to opposite side of body
vii. when necessary use pen light to inspect body cavities such as mouth and throat
viii. DO NOT HURRY AND PAY ATTENTION TO DETAIL!
Ask patient information about each abnormality of change |
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Term
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Definition
a. uses sense of touch, detects (resistance, resilience, roughness, texture, temperature and mobility),
i. use with or after visual inspection, assist patient in relaxing and positioning because muscle tension impairs ability to palpate correctly,
ii. palpate tender areas last, PALPATE ABDOMEN LAST, ask patient to point out areas more sensitive and record any nonverbal signs of discomfort,
consider i. Back of hand – sensitive to temperature
ii. Pads of fingertips – detect changes in texture, size, shape, consistency, and pulsation of body parts.
iii. Palm of hand – sensitive to vibration
iv. Nurse measures position, consistency and turgor by lightly grasping the body part with the fingertips.
v. Asking pt to take slow, deep breaths enhances muscle relaxation
vi. Palpate tender areas last
vii. Ask pt to point out that are more sensitive and note any nonverbal signs of discomfort
viii. Palpation is either light or deep and you control it by the amount of pressure you apply with the fingers or hand.
ix. Light palpation precedes deep palpation
x. Light palpation –
1. Apply pressure slowly, gently and deliberately
2. Depress about 1 cm (.5 in)
xi. Deep palpation
1. 2 cm (1 in)
2. Bimanual palpation – one hand placed over the other while applying pressure
xii. Seek assistance of a qualified instructor before attempting deep palpation STUDENTS DO NOT DO DEEP PALPATON
patient’s condition, area being palpated, and reason for palpation.
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Term
ORDER WHEN ASSESSING THE ABD |
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Definition
i. INSPECTION, AUSCULTATION, PERCUSSION, PALPATION |
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Term
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Definition
a. tapping the body part with fingertips to evaluate size, borders, and consistency of body organs and to discover fluid in body cavities.
i. Identifies the location, size, and density of underlying structures, character of sound depends on the density of underlying tissue. Two methods:
ii. Direct – striking the body surface directly with one or two fingers
iii. Indirect – middle finger of non-dominant hand firmly against the body surface, palm and fingers remaining off the skin, tip of the middle finger of the dominant hand strikes the base of the distal joint of the finger, use quick sharp stroke, and relax wrist to deliver proper blow.
Sounds produced by percussion |
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Term
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Definition
a. listening with a stethoscope to sounds produced by the body, listen in a quiet environment, important to listen to many normal sounds in order to recognize abnormal sounds when they arise, stethoscope must be placed directly on patients skin.
i. Characteristics of sound
ii. Frequency – number of sound wave cycles generated per second by a vibrating object.
iii. Loudness – amplitude of a sound wave
iv. Quality – sounds of similar frequency and loudness from different sources.
v. Duration – length of time the sound vibrations last.
vi. To be successful you must first recognize normal sounds from each body structure including the passage of blood through an artery, heart sounds and movement of air through the lungs
vii. P&P 110 Box 6-3 Using a stethoscope |
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Term
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Definition
a. – sense of smell to detect abnormalities that go unrecognized by other means, some alterations and bacteria create characteristic odors. (Table 6-3 page 111) |
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Term
Discuss the proper positioning of the client during the examination.
preparing pt. |
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Definition
a. Prepare pt both physically and psychologically for an accurate assessment
b. A tense anxious pt may have difficulty understanding, following directions or cooperating with your instructions
c. Make pt comfortable by allowing the opp to empty the bowel or bladder (a good time to collect needed specimens)
d. Promote privacy
e. Minimize pt anxiety and fear by conveying an open, receptive and professional approach
f. Use simple terms, thoroughly explain what you will do, what the pt should expect to feel and how the pt can cooperate, even if pt seems unresponsive, it is still important to explain your actions
g. Provide access to body parts while draping areas that are being examined
h. Reduce distractions
i. Turn down volume or turn off radio/television
j. Eliminate drafts, control room temp and provide warm blankets
k. Help the pt assume positions during the assessment so that body parts are accessible and the pt stays comfortable
l. Pt ability to assume positions will depend on physical strength and limitations
m. Some positions are uncomfortable or embarrassing
n. Keep pt in position no longer than is needed
o. Pace assessment according to the pt’s physical and emotional tolerance
p. Use a relaxed voice tone and facial expressions to put pt at ease
q. Encourage pt to ask questions and report discomfort felt during the examination
r. Have a third person of the pt gender in the room during assessment of genitalia, this prevents the pt from accusing the nurse of behaving in an unethical manner
s. At conclusion of the assessment ask the pt if there are any concerns or questions |
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Term
Discuss environment, equipment and client preparation for assessment |
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Definition
a. Make patient comfortable by allowing them to empty bowel and bladder ( collect specimens if needed )
b. Provide privacy
c. Minimize patient anxiety and fear by conveying an open, receptive, and professional approach. Explain what you are going to do and how they should expect to feel, and how they can cooperate.
d. Provide access to body parts while draping areas that are not being examined
e. Reduce distractions
f. Control room temperature and provide warm blankets
g. Help patient assume positions during exam so that body parts are accessible and patient stays comfortable, some positions are embarrassing or uncomfortable so DO NOT keep patient in position longer than necessary.
h. Pace assessment according to patient’s tolerance
i. Use relaxed tone and facial expressions
j. Encourage patient to ask questions and report discomfort
k. Have a third person present of patient’s gender when examining genitalia
l. Ask patient if there are any concerns or questions |
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Term
Discuss assessment of various age groups including children, adolescents and the older adult_
Children |
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Definition
i. Routine assessments focus on growth and development, vision and hearing screening, dental examination, and behavioral assessment
ii. Gain a child’s trust before doing any type of an exam
iii. Children feel safer during an examination if it is initiated from periphery and then moves to central
iv. Children whom are chronically ill, disable, in foster care, or adopted from a foreign country may require additional assessment because of their unique health risks
v. Gather all or part of information from parents or guardians
vi. Parents may think they are being tested or judged by the examiner
vii. Call child by preferred name and address parents by “mr. and or mrs. brown”
viii. Open ended questions often allow parents to share more information and describe more of child’s problems |
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Term
Discuss assessment of various age groups including children, adolescents and the older adult
a. Adolescents |
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Definition
i. Older children and adolescents tend to respond best when treated as adults and individuals and often can provide details about their health history and severity symptoms
Adolescent has the right to confidentiality, after talking with parents arrange to be alone with adolescent to speak further privately and to perform examination, use a chaperone |
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Term
1. Discuss assessment of various age groups including children, adolescents and the older adult_(P&P 112-113)
Older adults |
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Definition
i. Do not assume that aging is always accompanied by illness or disability
ii. Allow extra time, and be patient, relaxed and unhurried with older adults
iii. Provide adequate space for an examination
iv. Plan the history and examination taking into the account the older adult’s energy level, physical limitations, pace, and adaptability
v. Measure performance under most favorable conditions
vi. Sequence examination to keep position changes to a minimum
Be sure an examination of an older adult includes review of mental status |
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Term
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Definition
Flexion of hip and knee improves exposure of rectal and genitourinary areas
Areas Assessed
Rectum and Vagina
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Term
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Definition
Areas Assessed
Head, neck, back, posterior thorax, lungs, anterior lungs, breasts, axillae, heart, vital signs & upper extremities
Rationale
Supine |
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Definition
Areas Assessed
Head, neck, back, posterior thorax, lungs, anterior lungs, breasts, axillae, heart, vital signs & upper extremities
Rationale
Dorsal Recumbent |
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Definition
Areas Assessed
Head, neck, anterior thorax, lungs, breasts, axillae, heart, abdomen
Rationale
Position for abdominal assessment because it promotes relaxation of abdominal muscles
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Term
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Definition
Areas Assessed
Female genitalia & genital tract
Rationale
Prone |
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Definition
Areas Assessed
Musculoskeletal system
Rationale
Lateral recumbent |
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Definition
Areas Assessed
Heart
Rationale
Knee-chest |
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Definition
Areas Assessed
Rectum
Rationale
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