Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NSG2317 - health assessment > Assessment Techniques + Vital Signs > Flashcards

Assessment Techniques + Vital Signs Flashcards

1
Q

4 Moments of Hand Hygiene

A
  1. before initial patient/ patient environment contact
  2. before aseptic procedures
  3. after bodily fluid exposure risk
  4. after patient/ patient environment contact
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Assessment Techniques

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Ausculation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Inspection

A

concentrated watching –> visual evaluation of the patient as a whole THEN individual systems

  • performed first
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Palpation

A

physical contact with/ manipulation of the target structure –> used to confirm points noted during the initial inspection

assesses:
- texture: rigidity, spasticity, crepitation
- temperature, moisture
- organ location and size
- potential swelling
- vibration, pulsation
- presence of lumps or masses
- tenderness, pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Palpation: Steps

A
  1. Warm hands
  2. Select anatomy of focus, ensure adequate (but limited) exposure
  3. perform superficial palpation, then progress to deep palpation if necessary
    • use intermittent pressure not continuous
    • use the pads of your fingers
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Superficial Palpation

A

surface level <1cm deep
uses 1-2 hands

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Deep Palpation

A

3-4cm deep
usually uses two hands

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Palpation Technique: Fingertips

A
  • fine tactile discrimination - texture
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Palpation Technique: Grasping of Fingers + Thumbs

A
  • position
  • shape
  • size
  • consistency
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Palpation Technique: Back of Hands or Fingers

A
  • temperature
  • moisture
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Palpation Techniques: Base of Fingers or Knuckles

A
  • vibrations
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Percussion

A

the tapping of skin with short, sharp strokes to assess underlying structures with sound

sound can indicate the: location, size, and density of underlying organs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Direct Percussion

A

the striking hand makes direct contact with the patient’s skin
- uses only one hand (striking)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Indirect Percussion

A

the striking hand makes indirect contact with the patient’s skin, striking the stationary hand instead
- uses two hands (stationary and
striking)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Percussion: Steps

A
  1. flex the non-dominant hand so that the middle finger is hyperextended downwards
  2. position the hyperextended middle finger on the patient’s skin on the location you want to percuss - ensure no other fingers touch the skin (dampen sounds)
  3. strike just below the nail bed of the stationary hand’s middle finger with the tip of the dominant hand’s middle finger
  4. strike each location twice before moving to a new location
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Percussion Sounds: Dense Tissue

A

volume - dull thud
pitch - low, dense, muscular
duration - very short, solid, no echo
quality - description of sound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Percussion Sounds: Air-Filled Tissue

A

volume - loud, hollow
pitch - high, hollow
duration - long, echo (hollow space)
quality - description of sound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Ausculation

A

listening to sounds produced by parts of the body using a stethoscope

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Artifacts to Avoid

A
  1. ensure direct contact with skin - clothing can create excess noise
  2. avoid your own artifact - ensure that your clothing, hair, or otherwise do not bump into the stethoscope to create additional sounds
  3. keep the room warm - cold rooms may cause the patient to shiver, creating addition noise (muscle contractions)
  4. unnecessary friction - wet hair (chest hair, etc) prior to auscultation to avoid artifacts from the friction
  5. ensure a private, quiet room - background noises can create a “roaring” in the stethoscope
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Stethoscope: bell

A

deep, hollow, low-pitched sounds
- extra heart sounds
- murmurs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Stethoscope: diaphragm

A

high-pitched sounds
- bowel noises
- normal breath sounds
- manual blood pressure readings

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Vital Signs (5)

A
  1. Temperature
  2. Pulse
  3. Respiratory Rate
  4. pulse Oximetry
  5. Blood Pressure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Additional Vital Signs (2)

A
  1. Pain (Assessment)
  2. Level of Consciousness
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Normal Temperature

A

35.8 - 37.3 C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Temperature Locations

A
  1. Oral
  2. Axillary
  3. Tympanic Membrane
  4. Rectal
  5. Temporal
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Temperature: Influencing Factors

A
  1. Diurnal Cycle - temp fluctuates 1.5C throughout the day (lowest in the morning, highest in the evening)
  2. Menstruation Cycle - increases temp (progesterone)
  3. Exercise + Stress - SNS stimulation increases temp temporarily
  4. Consumption -
    • hot/ cold drinks changes the temp of
      the mouth
    • chew gum moves the mandible which
      increases oral temp
    • smoking dilates vessels increasing oral
      temp
  5. Age - decreases with age
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Oral Temperature

A

place covered probe (blue cover) under the tongue in one of the two sublingual pockets - close mouth and wait
- ensure thermometer is set to adult
oral and is in C
- dispose of cover immediately after

28
Q

When NOT to take an oral temperature

A
  • when the patient is unable to close their mouth (child, intubated)
  • when the patient cannot follow instructions
  • when the patient is unconscious
29
Q

Axillary Temperature

A

place covered probe (blue cover) into the axillary pocket and close arm - wait for reading
- ensure the thermometer is set to adult
axillary and in C
- dispose cover immediately after
- do NOT use for adults

30
Q

Rectal Temperature

A
  1. patient positioned on their left side with knees pulled up to their chest
  2. hand hygiene, don gloves, and place red probe cover on thermometer
  3. lubricate thermometer probe and insert in the direction of the umbilicus NO MORE than 1inch (2-3 cm) - hold and wait for reading
  4. dispose of probe immediately
31
Q

When to take a rectal temperature

A

To be used when other routes are not practical

  • when the patient is unconscious (coma)
  • when the patient cannot follow instruction
  • the patient cannot close their mouth (children, intubation)
32
Q

Tympanic Membrane Temperature

A

pull the helix of the ear up and back to straighten ear cannal, place cover on thermometer, and place probe into the ear in the direction of the nose
- ensure the thermometer is set to C
- look inside the ear canal for ear wax
that could interfere with reading

33
Q

Temporal Temperature

A

place the thermometer in the middle of the patient’s forehead, slide along the hairline to one side, and finish behind th ear
- less accurate
- should be used as an additional
reading, but not on its own

34
Q

Hyperthermia

A

> 38 C

35
Q

Hypothermia

A

<35 C

36
Q

9 Pulse Points

A
  1. Temporal
  2. Carotid
  3. Apical Impulse
  4. Brachial
  5. Radial
  6. Femoral
  7. Popliteal
  8. Anterior tibialis
  9. Dorsalis Pedis
37
Q

Normal Heart Rate

A

50-95 bpm

38
Q

Tachycardia

A

> 95 bpm

39
Q

Bradycardia

A

< 50 bpm

40
Q

Pulse Assessment

A

a. Rate - within, above, or below normal
range
b. Rhythm - regular or irregular
c. Force - 0, 1+, 2+, 3+
d. Equality - bilateral, equal

41
Q

Normal Respiratory Rate

A

10 - 20 breaths per minute

42
Q

Tachypnea

A

> 20 breaths per minute

43
Q

Bradypnea

A

< 10 breaths per minute

44
Q

Respiratory Assessment`

A

a. Rate
b. Effort
c. Rhythm
d. Depth
e. sound

45
Q

Pulse Oximetry (definition)

A

amount of oxygen reaching the tissues

46
Q

Normal Pulse Oximetry

A

> 95%

47
Q

Normal Blood Pressure

A

(<) 120 / 80

48
Q

(5) Factors Determining Blood Pressure

A
  1. Cardiac Output
  2. Vascular Resistance
  3. Blood Volume
  4. Blood Viscosity
  5. Elasticity of Vessel Walls
49
Q

Factors Affecting BP: Physiology

A
50
Q

Factors Affecting BP: Situational

A
51
Q

Korotkoff’s Sounds

A

Phase 1 - appearance of a thumping sound = systolic value

Phase 4 - muffling of the thumping sound

Phase 5 - thumping sound disappears, complete silence = diastolic value

52
Q

Orthostatic Hypotenison

A

an extreme change in blood pressure that occurs when the patient changes position
- dehydration
- hypertension + new htn meds
- history of syncope

Abnormal Changes:
systolic dec > 20
diastolic dec > 10
pulse inc > 20

53
Q

Hypotension

A

< 90/60 mmHg
- vasodilation (dec resistance)
- hemorrhage (dec blood volume)
- acute MI (occlusions, heart muscle
dies)

Symptoms:
- pallor, dizziness, confusion - low
perfusion (esp. to brain)
- tachycardia - compensation for low BP

54
Q

Hypertension

A

> 130/ 90 mmHg
- arteriosclerosis
increases risk for strokes

55
Q

Elevated Blood Pressure Value

A

120-129/80 mmHg

56
Q

Hypertension Stage I Value

A

130/ 80-89 mmHg

57
Q

Hypertension Stage II Value

A

> 140/ 90 mmHg

58
Q

Blood Pressure Errors

A
  1. Activation of the SNS (emotion, stress, exercise)
  2. <1-2 mins between readings
  3. incorrect arm position
  4. incorrect cuff size
  5. incorrect deflation of the cuff
59
Q

BP Error: Incorrect Cuff Size

A

too big = inc BP
too small = inc BP

60
Q

BP Error: <2mins between readings

A

inc diastolic BP - some blood will still be flowing and get trapped, leading to an artificially high diastolic reading

61
Q

BP Errors: Arm Position

A

above heart - dec BP (gravity assists)
below heart - inc BP (working against gravity)

62
Q

BP Errors: Deflating the Cuff

A

too quickly - dec systolic, inc diastolic

too slowly - inc diastolic

halting/ reinflating - dec diastolic

63
Q

Choosing the correct bladder length (BP cuff)

A

width = 80% arm circumference
length - 80-100% arm circumference

64
Q

Normal Vital Signs

A

temperature - 35.8-37.3
pulse - 50-95 bpm
respirations - 10-20 breaths per min
pulse oximetry - >95%
blood pressure - 120/80

65
Q

Abnormal Vital Signs

A

temperature - <35 or >38
pulse - <50 or >95
respirations - <10 or > 20
pulse oximetry - <95%
blood pressure - <90/60 or > 130/80

NSG2317 - health assessment (18 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions