Chapter 8: Physical Assessment Techniques

Question 1

What is a medical diagnosis?

Answer 1

The identification of the cause of the patient’s illness or discomfort

Question 2

What is a nursing diagnosis?

Answer 2

The patient problem identified by the nurse for nursing intervention by analysis of assessment findings in comparison with what is considered to be normal based on clinical experience and judgment.
A process that dictates a course of action for the nurse that is vitally important to the patient.

Question 3

What kind of diagnosis’ fits these terms?

1. )appendicitis
2. )impaired verbal communication
3. )impaired tissue integrity
4. )fractured left tibia
5. )risk for infection

Answer 3

1. ) medical
2. ) nursing
3. ) nursing
4. ) medical
5. ) nursing

Question 4

What are the 4 techniques done in every assessment in the same order except for the abdominal assessment?

Answer 4

inspection
palpation
percussion
auscultation

Question 5

What is inspection?

Answer 5

“Concentrated watching”
Simple but highly skilled technique
Begins the minute you first meet an individual
Involves the use of sight, hearing, and smell in a systematic fashion.
Body parts assessed for shape, color, symmetry, and odor
Requires good lighting
Always make side to side comparisons

Question 6

What is palpation?

Answer 6

Utilizing your hands
Warm hands before beginning
Keep fingernails short
Palpate areas of tenderness last, if at all.
Slow and systematic
Light palpation
Deep palpation
Fingertips: Pulsation, presence of lump, skin texture
Dorsa of hands / fingers: Temperature
Base of fingers: Vibration

Question 7

What is percussion?

Answer 7

Tapping the individual’s skin with short light strokes to identify underlying structure
Location, size, shape, and density
What underlies the site up to 5cm deep will determine the tone/sound that is heard.
Direct
Striking hand directly contacts body surface
Indirect
Used more often
Involves both hands
Striking hand contacts stationary hand fixed on person’s skin

Question 8

What is auscultation?

Answer 8

Systematic method of listening to sounds produced by the body
i.e. lung sounds and heart tones
Some sounds are audible with your ear alone, such as congested breathing
Always make side to side comparisons
Never listen through clothing
Always clean your stethoscope between uses!

Question 9

What sounds does the diaphragm pick up?

Answer 9

high-pitched sounds (breath, bowel and normal heart); used most

Question 10

What sounds does the bell pick up?

Answer 10

soft low-pitched sounds (extra heart sounds)

Question 11

When do we wash our hands?

Answer 11

Promptly and thoroughly 10-15 seconds
Before and after patient contact
After contact with blood / body fluids
After removing gloves

Question 12

What setting do we create for out patients when taking assessment?

Answer 12

Warm
Comfortable
Quiet
Private
Well lit
Prepared
Plan ahead – all equipment organized and ready
Designate a “clean” vs “dirty/used” field for equipment and supplies