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Health Assessment in Nursing (Ch. 8)
Exam 1 material (Jarvis Book)
45
Nursing
09/06/2010

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Cards

Term
What order do you perform "physical exam"?
Definition
Inspection
Palpation
Percussion
Auscultation
Term
Where do you change the order in which you perform the "physical exam"?
Definition
Abdomen: order is as follows:
Inspection
Auscultation
Palpation
Percussion
Term
Why do you Auscultate the abdomen before you palpate or percuss?
Definition
When you palpate and percuss the bowels you may stimulate bowel movements that does not represent the true state of the bowels. You want to listen to the bowels "as they are."
Term
When does inspection begin?
Definition
When you first enter a patients room or meet the patient. You are taking a "general survey".
Term
What could you do to train yourself not to "rush" into the assessment and remind yourself to thoroughly inspect the patient?
Definition
Perform inspection while holding your hands behind your back
Term
True or False: You should be inspecting for a person's symmetry by comparing the right and left side of the body.
Definition
True. The two side should be nearly symmetric.
Term
When you are palpating, what might you be searching for? (15 to list)
Definition
texture, temperature, moisture, organ size, organ location, swelling, vibration, pulsations, spasticity (twitching (spastic)), crepitation, lumps, masses, tenderness, pain
Term
What part of your hand is best for tactile discrimination? (Such as texture, swelling, determining lumps and masses?)
Definition
Fingertips
Term
What part of the hand is best for determining temperature?
Definition
Back of hand (dorsum of hand)
Term
What part of the hand is best for feeling vibration?
Definition
Base of fingers.
Term
If someone tells you they are having pain in their right abdomen before you begin palpation, what should you do?
Definition
Start at the location furthest away from the pain and using light palpation at first work in the direction of the pain. Noting where the pain begins.
Term
True or False: You should avoid any situation where deep palpation could cause internal pain or injury.
Definition
TRUE! DO not hurt the patient! Also, if there is a rupture, deep palpation could make things worse!
Term
Percussion is used for many reasons! Name 4.
Definition
1. It is free. Your hands are portable and with you everywhere. And gives instant feedback.
2.Allows you to map out location and size of certain organs.
3.Signals the density of a structure by a characteristic tone (air, fluid, solid)
4. Detect abnormal mass that is fairly superficial
5. Elicit pain if underlying tissue is inflamed.
Term
What type of percussion are you using when you directly tap on a patients sinuses?
Definition
Direct percussion
Term
What type of percussion are you using if you use the index finger of one hand and use a "striker" finger of your other hand?
Definition
Indirect percussion
Term
What sound do you hear if you percuss over bone?
Definition
Flat
Term
What sound would you expect to find over "normal lung tissue?" (while percussing)
Definition
Resonant
Term
What sound would you expect to find over a child's lung tissue or in someone with an increased amount of air in lungs? (while percussing)
Definition
Hyperressonance
Term
Where would you expect to hear "tympany" during a physical exam? (while percussing)
Definition
Air-filled viscus: stomach and intestines
Term
Where would you expect to hear dull sounds (while percussing)?
Definition
Dense organs: spleen or liver
Term
What end of the stethoscope would you use to listen for heart murmurs or extra heart sounds?
Definition
Bell
Term
Why should you press gently when listening with the bell?
Definition
If you press too hard, the bell will act as a diaphragm and obliterate low pitched sounds
Term
When should you use the diaphragm?
Definition
When listening to normal heart sounds, lung sounds, and bowel sounds.
Term
How often should you clean your stethoscope?
Definition
Before each use and between patients.
Term
You are auscultating the chest of a very hairy man who has come to your clinic with sprained ankle. Upon listening, you determine that man sounds like he has crackles in his lungs. What should you do next in this situation?
Definition
Wet the man's chest hair and listen again. A hairy chest may causes sounds that resemble the abnormal breath sound of "crackles".
Term
What instrument should you use to examine a patients otitis media?
Definition
Otoscope
Term
The doctor has asked you to bring him an opthalmoscope. You know that he will be examining what part of the patient?
Definition
Eyes
Term
True or false: You should wear eye protection, a mask, and gown when drawing blood from a healthy patients brachial artery?
Definition
False. You only need to wear this PPE when you anticipate there could be splashes of a patients body fluids. This needle stick should be uneventful.
Term
True or false. Recap a used needle before placing it in the sharps container?
Definition
False. Never recap a used needle.
Term
What type of precautions should you use with all patients?
Definition
Standard precautions. You should assume that all patients could have AIDS/HIV or similar disease (for your safety!)
Term
What is the single most important measure you can take to decrease the risk of microorganism transmission to yourself or others?
Definition
WASH YOUR HANDS
Term
How longer should you wash your hands? (in seconds)
Definition
10-15 seconds.
Term
What is the major developmental task for the infant? How might this affect your ability to perform an exam?
Definition
Trust. Parent should always be present. Smile. Use a soft crooning voice, Bright colored toys for distraction. Pacifier.
Term
When should you elicit the Moro or startle exam on an infant?
Definition
Last! This may make the infant cry... and then how can you do the rest of the exam?
Term
What age groups should you perform the "Eye,Ear, nose and throat" exam until last?
Definition
Infant, toddler, preschooler.
Term
The developmental stage for the toddler is what?
Definition
Autonomy.
Term
Developmental stage for the preschool child?
Definition
Initiative. Usually cooperative, helpful and easy to involve.
Term
School age child's stage of development?
Definition
Developing industry. Perform exam from head to toes.
Term
Adolescent major developmental task? How will this effect how you perform an exam?
Definition
Self-identity. Use a head to toe approach but do genital exam LAST and be brief.
Term
If you are performing an exam on an ill person, you may do a "mini" or focused exam which is problem focused and complete a full assessment after distress is resolved.
Definition
Term
In examining persons across the lifespan, it is important to consider:
Definition
1.the developmental stage when determining the sequence of the exam.
2.privacy for all ages.
3.pacing the examination to meet the physical, mental, and emotional needs of the aging adult.
Term
What technique is used to elicit the deep tendon reflex?
Definition
Percussion
Term
Fundoscopic exam is an exam of the?
Definition
Eye
Term
At the end of the exam, the nurse should:
Definition
Review findings with the patient.
Term
What must be considered when examining the older adult?
Definition
1. Base the pace of the examination on the patient's individual needs and abilities.
2. Use physical touch to offset the disadvantages of diminishing vision and hearing.
3. Beware that loss is inevitable and adaptation to loss affects health status.