Unit 2: Approach to clinical setting Flashcards Preview

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Flashcards in Unit 2: Approach to clinical setting Deck (45)
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1

Proper Hand Washing Technique

- 15-20 seconds "happy birthday" twice
- luke warm water and antibacterial soap

2

c-diff

smelly, painful, explosive diarrhea every 15 minutes
- can last 6-8 weeks in a health person

3

Tools of physical assessment

insepction, palpation, percussion, auscultation

4

Inspection

- visual exam of body including movement and posture. smell also
use of equipment may help:
* penlight -eyes, dilation
* otoscope - ears, tempanic membrane
* ophthalmoscope - eyes, distribution of blood vessels, retina
* nasal speculum - open up nose and look
* vaginal speculum
* woods lamp (black light) for fungal infections or corneal abrasion)

5

palpation

- use of hands to feel texture, size, shape, consistency, location of certain parts, and identify painful or tender areas
- requires nurse to move into personal space
- gentle touch, warm hands, short nails
- Light and Deep (requires training, can rupture spleen or gallbladder)

6

parts of hands for palpation

* fingertips: skin texture, swelling (edema), pulsations, lumps
* fingers and thumb (grasping): shape, consistency of an organ or mass
* dorsal of hands and fingers: temperature
* base of fingers/ulnar surface of the hand: vibrations

7

Percussion

* yields characteristic vibration sounds
* determines density, location and size of underlying organs or to elicit DTRs
LUNGS = resonance = air
ABDOMEN = fluid/air = tympany
ORGAN/MASS = solid = dullness
BONE = dense = flat

* hyperresonance = too much air (COPD)
Use percussion in two areas:
1: costal vertebral angle - back where ribs end - kidney stones, kidney infection
2: Sinuses: sinus infection

8

indirect percussion

* use middle finger only
- tap twice and lift up
- you can use this to estimate the size of organs

9

Auscultation

listen to sounds within the body with a stethoscope
- listen for sound characteristics: intensity, pitch, duration and quality
- DIAPHRAGM: high pitch noises (respirations, abdomen)
- Bell: Low pitch (heart,

10

patient positioning

- move no more than 4 times throughout exam. laying, sitting, standing, sitting
- lithotomy position - vaginal exam in stirrups
- trandelenburg - feet up higher than head (central line placement)

11

thermometers

electronic:
tympanic: ear - varied accuracy
temporal: uses in fared, highly accurate

12

stethoscope

diaphragm: high pitched sounds, respiratory, bowel sounds, normal heart sounds
Bell: soft/low-pitched sounds - extra heart sounds, vascular sounds,

13

sphygmomanometer

measures arterial blood pressure

14

pulse ox

measures arterial oxygen saturation in blood
- % of hemoglobin that is binded to an oxygen molecule

15

weight

daily weight certain patients:
- CHF patients (edema)
- gastric bypas (weight loss surgery)
- dialysis patients (urinary issues)
- infants with failure to thrive

16

visual acuity and screening

snellen chart is a wall chart placed 20 ft from patient
- E chart is used for young children and on-english speaking patients

17

otoscope

used to look at tyrannic membrane. sends small puffs of air to evaluate fluctuation of tympanic membrane in children

18

penlight

- illuminate mouth or nose
- highlight a lesion
- evaluate pupillary constriction

19

nasal speculum

used to inspect lower and middle turbinates of the nose.

20

tuning fork

auditory screening and and vibratory sensation

21

reflex hammer

used to test deep tendon reflexes "percussion hammer"

22

doppler

usees ultrasonic waves to detect and amplify difficult-to-hear vascular sounds such as fetal heart sounds and peripheral pulses

23

goniometer

degree of flexion and extension of joint

24

monofilament

used to test lower extremity sensation
- small, flexible wirelike deice attached to handle NEURO

25

transilluminator

used to differentiate characteristics of tissue, fluid, air in specific body cavity

26

woods lamp

detects fungal infection of skin, detects corneal abrasions (with use of florescent dye)

27

general inspection

begins the moment the nurse meets the patient
- physical appearance, hygiene, body structure and movement, emotional and mental status, behavior
- use this to guide your health assessment
- note: assistive divice for walking, happy/depressed, dressed appropriate for weather, wounds, hygiene

28

chachexia

very very thin and malnourished

29

VITAL signs

weight
Height
temperature
pulse
respiratory rate
Blood Pressure
02 saturation

30

Weight

BMI: overweight = 25-30
obese = 30 - 34
morbidly obese = 35+

weight to hip ratio is important
android obesity = around the middle
synoid obesity = butt