Flashcards in Weeks 3 & 4: Physical Exam, Vitals, Pain, Skin/hair/nails, violence Deck (98)
what is the typical order of physical assessment (except if doing abdominal)
inspect (always first!)
Indirect percussion technique is used to determine
what is happening in the underlying structures – evaluated by auscultating the sounds.
where do you expect to hear "resonant" sound
normal lung tissue (clear and hollow sound)
in an abnormal adult lung (but a NORMAL child's lung)
air-filled viscus (stomach, intestine)
dense organ (liver, spleen)
large muscles (thigh), bone, tumor
when does the general survey begin
with the first moment of encounter!
Hyper pituitary dwarfism
lack of growth hormones-disproportionate body parts
excessive growth hormones in body
excess of cortisol
too little cortisol
genetic disorder affects body's connective tissue
the condition of having some or all of the fingers or toes wholly or partly united, either naturally (as in web-footed animals) or as a malformation
normal temperature ranges
oral temp is 35.8C-37.3 C (96.4F-99.1F)
Rectal temp is 0.5C (1.0F) HIGHER
Axillary temp is 0.5C (1.0F) LOWER
normal pulse of adult is 60-100 bpm (never use thumb!)
we listen for these when taking blood pressure.
5 sounds (1st sounds we hear is the systolic. Last sound is diastolic)
should be >90%. BUT, if pt is diagnosed with COPD, we do NOT want their O2 to be >90%. So, if they are at 87% we do NOT give them O2.
what pain scale do we use with demented PTs
Neonate responses to pain
global, evidenced by increased heart rate, hypertension, pallor, sweating, and decreased oxygenation saturation.
What intervention is most important to prevent nosocomial infections?
The patient is complaining of abdominal pain. What technique is used to form an overall impression
Tympany is a percussion sound commonly located in the
Percussion sounds are hyperresonant (diseased lungs), resonant (normal lungs), tympanic (abdomen), dull (over organs), and flat (over bone).
Which organs or body areas does the nurse auscultate as part of the admitting assessment
Heart, lungs, and abdomen
the diaphragm of the stethescope is used for ____ sounds
high frequency sounds (e.g. bowel sounds)
the bell of the stethescope is used for _____ sounds
low-frequency sounds (carotid arteries, bruit)
When assessing the child, the nurse makes the following adaptation to the usual techniques:
A pediatric stethoscope is used for better contact
The general survey includes
overall appearance, hygiene and dress, skin color, body structure and development, behavior, facial expression, level of consciousness, speech, mobility, posture, range of motion, and gait.