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39 Cards in this Set
- Front
- Back
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List the methods of assessment. (Should be performed in this order)
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Inspection
Palpation Percussion Auscultation |
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During inspection what senses are used?
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Sight
Smell Hearing |
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What is the purpose of inspection
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Examiner takes information and forms opinions that will help in decision-making
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Used to augment data gathered during inspection
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Palpation
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Press palmar surface of fingers 1-2 cm into body using circular motion
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Medium palpation
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Press palmar surface of fingers 2-4 cm into body using circular motion
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Deep palpation
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Assesses for lesions on surface or within muscle
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light palpation
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What does percussion determine?
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Determines
Position Size Density Fluids/Air |
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Involves striking the body surface lightly, but sharply
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Percussion
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Louder, lower, longer sound
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Lungs
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Softer, higher, shorter sound
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Thigh muscle
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Listening to body sounds created by
Lungs: movement of air Heart: heart sounds Blood vessels: carotid arteries, BP Abdominal viscera: bowel sounds |
Auscultation
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Why do we measure height?
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Monitor for ↓ bone density or osteoporosis and its Often used to evaluate body proportion
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Why do we measure weight?
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Often to evaluate nutritional and overall health status
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How would you assess HR?
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Peripheral pulse is used to assess HR (radial pulse)
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When would you count heart beats for a minute?
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If pulse rhythm is irregular, count beats for 1 min. ( also applies for RPM)
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Normal HR for adult?
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60-100 bpm
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Normal RR for adult?
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12-20 RPM
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What is BP?
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Force of blood as it pushes against the arterial walls
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Indirect measurement of BP
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Auscultatory method
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Korotkoff sound indicating diastolic?
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Phase V: cessation of sound (DIASTOLIC)
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Korotkoff sound indicating systolic?
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Phase I: faint, clear tapping (SYSTOLIC)
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swooshing
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Phase II
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Phase III
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clear tapping
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Phase IV
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muffling
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Where is the stethoscope placed during the measurement of BP?
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brachial artery
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Which info should be reported in the measurement of BP?
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Numerical value in even numbers
Patient’s position (sitting, standing, lying) Cuff size Arm used for measurement |
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If BP needs to be taken again how long should a patient wait?
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wait 1-2 mins
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Deflating the cuff too quickly can cause?
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May not allow enough time to hear the systolic pressure
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Deflating the cuff too slowly can cause?
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May cause forearm venous congestion --> falsely high diastolic reading
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Halting during deflation and reinflation causes?
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May cause forearm venous congestion --> falsely high diastolic reading
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Incorrect cuff size used: Too small/Too large can cause?
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Too small : falsely high reading
Too large : falsely low reading |
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Failing to position arm at heart level can cause
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Above heart level: falsely low reading
Below heart level: falsely high reading |
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Not allowing patient to rest 5 minutes prior to measurement causes?
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falsely high reading
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what can cause a falsely high reading?
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Anxiety, pain, discomfort, strenuous activity
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list some Physiological indicators of pain.
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Tachycardia
Tachypnea Sweating Pallor Extreme anxiety Physical appearance (i.e., red, swollen) |
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What is the Wisconsin Brief Pain Questionnaire?
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17 questions that assess various aspects of pain
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list some behavioral observations of someone in pain.
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Verbal complaints
Taking of medicine Seeking treatment Change in physical or social functioning Facial expressions Body movements Vocalizations |
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PQRST??
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P Palliative or precipitating factors
Q Quality of pain R Region where the pain is located or radiation of the pain S Severity of pain T Temporal or time-related nature of the pain |
