Nursing 202

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Author:
stephanie831
ID:
41021
Filename:
Nursing 202
Updated:
2010-10-10 03:58:19
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Nursing Examination Assessment techniques
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Description:
Examination/Assessment Techniques
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  1. What are four physical assessment techniques?
    • Inspection
    • Palpation
    • Percussion
    • Auscultation
  2. What is inspection and what do you do?
    • observation
    • 1) general observation of the whole body, then specific body systems
    • 2) assess symmetry (compare both sides)
    • 3) use your senses (visual, smell, hearing)
  3. What is palpation and what do you do?
    • touch
    • hands
    • - 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
    • Bimanual (use of both hands to capture organ)- e.g. pelvic exam-uterus
  4. What is percussion?
    yielding a palpable vibration
  5. 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)
  6. Percussion helps elicit ________.
    pain (if inflammation is present)
  7. What are the two types of percussion?
    • 1. Direct (strike body directly) e.g. percuss sinuses in an adult
    • 2. Indirect (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
  8. How would you directly and indirectly percuss the costoverterbral angle tenderness (CVAT)?
    • Direct: use fist (ulnar surface) to percuss directly over the CVA
    • Indirect: Examiner places his/her hand over the patient's CVA and then provides moderate force when striking his or her hand
  9. How do you percuss deep tendon reflexes (DTR)
    use a reflex hammer
  10. What is auscultation?
    listening with stethoscope
  11. What is the diaphragm used for?
    high pitched sounds- breath sounds, bowel sounds, normal heart sounds
  12. What is the bell used when auscultating?
    low pitched/soft sounds-rest bell gently on the skin to hear extra heart sounds and murmurs

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