Card Set Information
Nursing Examination Assessment techniques
What are four physical assessment techniques?
What is inspection and what do you do?
1) general observation of the whole body, then specific body systems
2) assess symmetry (compare both sides)
3) use your senses (visual, smell, hearing)
What is palpation and what do you do?
- fingertips (most sensitive to fine tactile discrimination)
- skin texture, swelling, pulses and lumps or masses
- metacarpo-phalangeol joints (MCP) or ulnar surface of hands (assess vibration)
Use light palpation (1 cm) followed by deeper palpation
(use of both hands to capture organ)- e.g. pelvic exam-uterus
What is percussion?
yielding a palpable vibration
Percussion reflects: (3)
1) location and size of organ
2) density (air, fluid, solid mass)
3) superficial masses (less than or equal to 5 cm)
Percussion helps elicit ________.
pain (if inflammation is present)
What are the two types of percussion?
(strike body directly) e.g. percuss sinuses in an adult
(2 handed technique)- strike finger ay DIP joint
-Resonant (normal lungs)
- Hyperresonant (hyperinflated alveoli)-r/t COPD
- Tympany (air filled organ) -intestine and stomach
- Dull (dense organ)- liver, consolidated lung, full bladder
- Flat- muscle, bone, tumor
How would you directly and indirectly percuss the costoverterbral angle tenderness (CVAT)?
: use fist (ulnar surface) to percuss directly over the CVA
: Examiner places his/her hand over the patient's CVA and then provides moderate force when striking his or her hand
How do you percuss deep tendon reflexes (DTR)
use a reflex hammer
What is auscultation?
listening with stethoscope
What is the diaphragm used for?
high pitched sounds- breath sounds, bowel sounds, normal heart sounds
What is the bell used when auscultating?
low pitched/soft sounds-rest bell gently on the skin to hear extra heart sounds and murmurs