NURS 207: Week 2 + Sherpath Lesson: Examination Techniques
What are some advantages of taking a tympanic temperature?
- Advantages of speed, convenience, safety, reduced risk for injury and infection, and non-invasiveness
What are factors that effect BP?
- Age: gradual rise through childhood and into adult years - Gender: after puberty, females show a lower BP than males; after menopause, females higher than males - Race: Differences exist relative to combination of genetics and environment. - Diurnal rhythm: Daily peak and trough levels r/t timing cycles - Weight: Obesity increases blood pressure as compared to normal weight recorded measurements of same age. - Exercise: Will cause a transitory increase in blood pressure - Emotions: Will increase in response to sympathetic nervous system response - Stress: Will increase in response to increased stress and tension
What should a nurse do irregularities are felt in the heart rate?
- Auscultate heart sounds for a more complete assessment.
The level of BP is determined by 5 factors. What are they?
- Cardiac output: increase in CO leads to increase in BP whereas decrease in CO leads to decrease in BP - Peripheral vascular resistance: increased resistance (vasoconstriction) leads to increase in BP whereas decrease in resistance(vasodilation) leads to decrease in BP - Volume of circulating blood: fluid retention leads to increased BP whereas hemorrhages leads to decreased BP - Viscosity: increase associated with increase in BP - Elasticity of vessel walls: increasing rigidity associated with increase in BP
Proper cellular metabolism requires what in regard to temperature?
- Cellular metabolism requires a stable core, or "deep body," temperature of 37.2° C (99° F). - Body maintains steady temperature through feedback mechanism regulated in hypothalamus of brain. - Balances heat production with heat loss - Various routes of temperature measurement reflect body's core temperature.
What are the basic principles of auscultation?
- Eliminate extra noise. - Keep environment warm and warm your stethoscope. - Avoid listening over hairy body areas. - Never listen through a patient's gown or clothing. - Avoid your own artifact.
What is the palpation technique for measuring an irregular pulse?
- For irregular pulse, count for full minute. - Assess pulse for rate, rhythm, force, and elasticity.
What are some uses of percussion?
- Mapping location and size of organs - Signaling density of a structure by a characteristic note - Detecting a superficial abnormal mass - Eliciting pain if underlying structure is inflamed - Eliciting deep tendon reflex using percussion hammer
Why is there minimal chance of cross-contamination with a tympanic thermometer?
- Minimal chance of cross-contamination with tympanic thermometer because ear canal is lined with skin
What are some important facts about oral temperature?
- Oral temperature accurate and convenient - Oral sublingual site has rich blood supply from carotid arteries that quickly responds to changes in inner core temperature. - Normal oral temperature in a resting person is37° C (98.6° F), with a range of 35.8° C to 37.3° C (96.4° F to 99.1° F)
What is the difference between orthostatic and normal BP readings?
- Position changed from supine to standing, normally slight decrease (less than 10 mm Hg) in systolic pressure may occur.
What is pulse pressure?
- Pulse pressure: difference between systolic and diastolic ■Reflects stroke volume
What are some factors that affect heart rate?
- Rate normally varies with age. - Rate also varies with gender after puberty, females have slightly faster rate than males. - Stronger, more efficient heart muscle pushes out a larger stroke volume with each beat, thus requiring fewer beats per minute to maintain a stable cardiac output. -stress -exercise
What is the difference between oral and rectal temperature?
- Rectal measures 0.4° C to 0.5° C (0.7° F to 1° F) higher
How should the nurse document temperature?
- Report route and temperature in degrees Celsius or Fahrenheit.
What is an irregular heart rhythm commonly found child?
- Sinus dysrhythmia
The strength of push changes with each event in the cardiac cycle. What is the difference between ventricular contraction and ventricular relaxation? ○Mean arterial pressure (MAP): pressure forcing blood into tissues, averaged over cardiac cycle
- Systolic pressure: maximum pressure felt on artery during left ventricular contraction, or systole - Diastolic pressure: elastic recoil, or resting, pressure that blood exerts constantly between each contraction
In what specific scenarios is a taking tympanic temperature utilized?
- Used with unconscious patients or with those who are unable or unwilling to cooperate with traditional techniques
What is the palpation technique for measuring a regular pulse?
- Using pads of the first three fingers - If rhythm is regular, count number of beats in 30 seconds and multiply by 2. - The 30-second interval is most accurate and efficient when heart rates are normal or rapid and when rhythms are regular. - Assess pulse for rate, rhythm, force, and elasticity.
What is it important to do when taking the temperature of a patient who just drank ice water or smoked?
- Wait 15 minutes if person has just taken hot or iced liquids and 2 minutes if he or she has just smoked.
Compare and contrast a weak vs. strong pulse and how is pulse force recorded?
- Weak, thready pulse reflects a decreased stroke volume (e.g., as occurs with hemorrhagic shock). - Full, bounding pulse denotes increased stroke volume, as with anxiety, exercise, and some abnormal conditions. - Pulse force recorded using three-point scale ■3+ Full, bounding ■2+ Normal ■1+ Weak, thready ■0 Absent
When would a nurse take an orthostatic or postural vital sign?
- You suspect volume depletion. - Person is known to have hypertension or taking antihypertensive medications. - Person reports fainting or syncope.
What mean arterial pressure (MAP)?
- pressure forcing blood into tissues, averaged over cardiac cycle
How do you count for regular and irregular respirations?
-AVOID MAKING THE PATIENT AWARE that ur taking their resp rate - count for 30 seconds and multiply by 2 for regular rate - count a full minute if abnormality is expected
(light and deep) Palpation applies sense of touch to assess the following:
-Texture, temperature and moisture -Organ location and size -Swelling, vibration, pulsation or crepitation -Rigidity or spasticity -Presence of lumps or masses -Presence of tenderness or pain
Steps for indirect percussion technique
1. Expose patient's skin by removing gown as needed. 2. Place middle finger of nondominant hand firmly on patient's skin. 3. Keep the fingers of the nondominant hand fanned out and off the surface of the skin. 4. Snap the wrist of the dominant hand downward. 5. With dominant hand, strike the middle finger of nondominant hand.
What is the average BP in young adults?
120/80 mm Hg
The width of the rubber bladder of a BP cuff should equal how much percent of the circumference of a patient's arm? The length should be equal to what percent of the circumference?
40%, 80%
What is considered a fairly consistent ratio of pulse rate to respiratory rate?
4:1
What are Korotkoff sounds?
= sounds heard when taking blood pressure ●Phases of sound: I through V - Note first appearance of sound (systolic) - Hear muffling of sound. - Hear final disappearance of sounds (diastolic) ●Clear communication is important because results significantly affect diagnosis and planning of care.
What is tachycardia?
A more rapid heart rate, over 100 bpm, is tachycardia. ■Occurs normally with anxiety or with increased exercise to match body's demand for increased metabolism
What is body mass index (BMI)?
A number that represents a weight-to-height ratio -Body mass index is practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition.
A nurse is collecting data for a client's comprehensive physical examination. After inspecting the client's abdomen, which of the following skills of the physical examination process should the nurse perform next? A: Olfaction B: Auscultation C: Palpation D: Percussion
A. Olfaction is the use of sense of smell to detect any unexpected findings that cannot be detected via other means (a fruity breath odor). Unless there is an open lesion on the client's abdomen, this is not the next step in the abdominal examination. B. CORRECT: Because palpation and percussion can alter the frequency and intensity of bowel sounds, auscultate the abdomen next and before using those two techniques. C. Palpation is the next step in examining other areas of the body, but not the abdomen. D. Percussion is important for detecting gas, fluid, and solid masses in the abdomen, but it is not the next step in the abdominal examination.
Which condition is necessary for accurate inspection? Adequate time to complete exam Dark, calming room with an examination table Patient is quiet and motionless Examination room with sunny window
Adequate time to complete exam
Which part of the hand is best used to assess for fremitus, or vibrations? Finger pads Ball of hand Back of hand Forefinger and thumb
Ball of hand
The nurse percusses the patient's chest and notes a loud, low, hollow tone. The nurse notes this is an expected finding when assessing over which body area? Bone Upper liver Lungs Heart
Bone Muscles and bones have a flat sound that is a high-pitched, soft tone, and not a loud, low, hollow tone. Upper liver Dense organs, such as the liver, have a dull sound that is a high-pitched, thudding tone, and not a loud, low, hollow tone. Lungs Lungs have a resonant sound that is a loud, low, hollow tone. Heart The heart will have a dull tone and not a loud, low, hollow tone.
The nurse is preparing to use the middle finger of the dominant hand to tap on the middle finger of the nondominant hand, which is placed on the patient's chest. Which type of percussion is the nurse using? Direct Indirect Blunt Immediate
Direct Direct percussion uses short, sharp strokes of the fist or fingertips of the dominant hand to tap the patient. Indirect Indirect percussion uses the middle finger of the dominant hand to tap on the middle finger of the nondominant hand, which is placed on the patient. Blunt Blunt percussion uses the ulnar surface of the fist to deliver a firm thump. Immediate Immediate percussion uses short, sharp strokes of the fist or fingertips of the dominant hand to tap the patient.
Match the percussion technique with the expected findings. Resonance of lungs Tenderness of kidney Tympany of liver Hyperresonance of lungs Flat sound on spine Direct (immediate) Indirect (mediate) Blunt (fist)
Direct (immediate): Flat sound on spine Indirect (mediate): Resonance of lungs Blunt (fist): Tenderness of kidney
Which techniques help identify percussion tones? Downward snap of the forearm Slowly snapping back the wrist after striking Striking with the fingertips Alternately striking directly on and then distal to the interphalangeal joint
Downward snap of the forearm The downward snap of the wrist, not the shoulder or forearm, will help identify percussion tones. Slowly snapping back the wrist after striking The wrist should be rapidly snapped back after striking to avoid dampening the sound. Slowly snapping back the wrist after striking will not help identify percussion tones. Striking with the fingertips Striking with the fingertips, instead of the finger pads, will help identify percussion tones. Alternately striking directly on and then distal to the interphalangeal joint Avoid varying the striking location on the middle finger because the percussion tones will not be the same in both places; choose either directly over the joint or just distal to it but remain consistent.
Which techniques are required to conduct accurate percussion? Select all that apply. Downward snap the striking finger Tap sharply and rapidly Slowly lift finger to damp sound Use the tip of the finger to strike Have short fingernails
Downward snap the striking finger Tap sharply and rapidly Use the tip of the finger to strike Have short fingernails
What guidelines should the nurse follow to ensure that auscultation sounds are accurately heard? Encourage the patient to ask questions during auscultation Focus on counting the respiratory rate while auscultating the abdomen Ensure that the stethoscope endpiece is firmly held against the skin Place the stethoscope over a sheet while auscultating a patient who is "cold"
Ensure that the stethoscope endpiece is firmly held against the skin
(T/F): A stethoscope magnifies sounds
F: Stethoscope does not magnify sound, but it blocks out extraneous sounds
Which part of the hand is used to palpate the patient's abdomen? Finger pads Ball of hand Back of hand Forefinger and thumb
Finger pads
Which part of the hand would the nurse use to palpate pulsations? Finger pads Ball of hand Back of hand Forefinger and thumb
Finger pads
Match the following assessment with the part of the hand best suited to obtain accurate assessment data. Temperature and moisture Texture and shape Nodules and tissue size Vibrations and thrills Eliciting reflexes Testing grip and muscle strength Finger pads: Ball of hand: Back of hand: Forefinger and thumb:
Finger pads: Texture and shape Ball of hand: Vibrations and thrills Back of hand: Temperature and moisture Forefinger and thumb: Nodules and tissue size
Which tone would the nurse expect to hear when percussing over bone? Tympany Dullness Resonance Flatness
Flatness
When conducting the assessment of a new patient, inspection begins with which step? General inspection of the patient Head-to-toe inspection of the patient Systematic inspection of the patient Focused inspection of the patient
General inspection of the patient The nurse should begin the examination with a general inspection because this preliminary observation provides basic information that can influence the rest of the examination. Head-to-toe inspection of the patient The nurse should not begin the examination with head-to-toe inspection because preliminary observation is needed first and will influence the head-to-toe inspection. Systematic inspection of the patient The nurse should not begin the examination with systematic inspection because preliminary observation is needed first and will influence the systemic inspection. Focused inspection of the patient The nurse should not begin the examination with focused inspection because preliminary observation is needed first and will influence the focused inspection.
Match the auscultation guidelines with correct rationale. Decreases examination proficiency Prevents distraction Distinguishes between two sounds Encourages obscured sounds Avoids obscured sounds Important to identify characteristics Have a quiet environment Auscultate directly on skin Take time for auscultation Listen to one sound at a time
Have a quiet environment: Prevents distraction Auscultate directly on skin: Avoids obscured sounds Take time for auscultation: Important to identify characteristics Listen to one sound at a time: Distinguishes between two sounds
Match the body area with the expected tone heard during percussion. Flat, Dull, Tympanic, Absent, Resonant, Hyperresonant Healthy lung tissue: Muscle of thigh: Abdomen over stomach: Abdomen over liver:
Healthy lung tissue: Resonant Muscle of thigh: Flat Abdomen over stomach: Tympanic Abdomen over liver: Dull
What percussion tone would indicate air-filled (emphysematous) lungs? Hyperresonance Dullness Resonance Flatness
Hyperresonance
What are abnormal findings associated with vital signs?
Hypotension -Seen in acute myocardial infarction (AMI), shock, hemorrhage, vasodilation, and/or Addison's disease Essential or primary HTN -BP Pressure Guidelines ■ACC/AHA Task Force■JNC-8 Guidelines Cardiovascular risk stratification ■Major risk factors impacting target organs ■Smoking, dyslipidemia, diabetes mellitus, above 60 years of age, gender (men and postmenopausal women), and family history of cardiac disease
In a resting adult, what is the normal heart rate range?
In resting adult, normal heart rate range is 60 to 100 beats per minute (bpm).
What is included as part of the general inspection? Inspecting the mouth and throat Assessing edema on legs Checking size of a scar Observing overall appearance of patient
Inspecting the mouth and throat Inspecting the mouth and throat is part of the systematic assessment but not part of the general inspection. Assessing edema on legs Assessing edema on the legs is part of the focused assessment but not part of the general inspection. Checking size of a scar Checking the size of a scar is part of the systematic assessment but not part of the general inspection. Observing overall appearance of patient Inspecting the overall appearance of the patient is part of the general inspection.
Which auscultation techniques are correct for auscultating the heart and lungs? Select all that apply. Isolate each sound and listen to it separately Talk with the patient while auscultating Listen to the heart and lungs simultaneously Focus on the characteristics of each sound Anticipate the patient's next inhalation
Isolate each sound and listen to it separately Focus on the characteristics of each sound
What steps can the nurse take to isolate auscultation sounds and facilitate accurate assessment findings? Select all that apply. Listen to one sound at a time Close eyes to focus on sounds Anticipate the next sound heard Block out environmental noises Distinguish sound from other sounds
Listen to one sound at a time Listening to one sound at a time will ensure accurate auscultation findings. Close eyes to focus on sounds Closing the eyes can help prevent distractions and ensure accurate auscultation findings. Anticipate the next sound heard Anticipating the next sound heard can result in inaccurate findings and should be avoided. Block out environmental noises Blocking out environmental noises allows the nurse to focus on sounds heard and ensures accurate auscultation findings. Distinguish sound from other sounds Distinguishing the sound being ascultated from other sounds within the body ensures accurate auscultation findings.
Which techniques help correctly identify auscultation sounds? Select all that apply. Listening for the presence of sound Noticing the characteristics of sound Angling the stethoscope earpieces in the ear correctly Placing the stethoscope on the patient's skin Auscultating over the patient's gown
Listening for the presence of sound The nurse must listen for the presence of a sound when auscultating. Noticing the characteristics of sound The nurse should notice the intensity, pitch, duration, and quality of sounds when auscultating. Angling the stethoscope earpieces in the ear correctly Angling the stethoscope earpieces in the ear correctly can help identify sounds when auscultating, because it allows the nurse to hear sounds more accurately. Placing the stethoscope on the patient's skin Placing the stethoscope directly on the patient's skin ensures accurate auscultation findings. Auscultating over the patient's gown Auscultating over the patient's gown can result in inaccurate findings and does not help correctly identify sounds.
Bimanual palpation is best used to assess which area of the body? Liver and large intestine Female reproductive organs Pulsations of femoral artery Skin of the posterior thorax
Liver and large intestine Deep palpation is best for assessing abdominal structures, particularly the liver. Female reproductive organs Bimanual palpation is required to examine the texture and firmness of some organs, including female reproductive organs. Pulsations of femoral artery Light palpation, not bimanual palpation, is best for assessing pulsations. Skin of the posterior thorax Light palpation, not bimanual palpation, is best for assessing skin.
What are some things that influence temperature?
Normal temperature is influenced by the following: - Diurnal cycle of 1° F to 1.5° F, - Menstruation cycle in women - Exercise - Age: wider normal variations occur in infant and young child due to less effective heat control mechanisms; in older adults, temperature usually lower than in other age groups, with a mean of 36.2° C (97.2° F)
Which component is included as part of a systematic inspection? Observing patient front to back Checking patient for obvious injuries Assessing overall patient appearance Inspecting each body region from head to toe
Observing patient front to back Observing a patient front to back and from each side are components of a general inspection. Checking patient for obvious injuries Checking a patient for the presence of obvious injuries is a component of a general inspection. Assessing overall patient appearance Assessing the overall appearance of a patient is a component of a general inspection. Inspecting each body region from head to toe Inspecting each body region, in a head to toe fashion, is a component of a systematic inspection.
What components are included in a general inspection of the patient? Select all that apply. Overall color of skin Symmetry of body Color of scalp Obvious injuries Shape of thorax
Overall color of skin Obvious injuries
To ensure accurate findings, what information would the nurse verify prior to beginning inspection? A clock with a second hand is present in the room. The patient is completely covered with a drape at all times. History-taking questions have been answered. Overhead lighting and a lamp are available.
Overhead lighting and a lamp are available.
During an abdominal assessment, palpation occurs after auscultation for what reason? Palpation can cause the patient to experience pain. Auscultation always follows inspection. Palpation may increase intestinal activity. Auscultation can be time-consuming.
Palpation may increase intestinal activity.
What is the procedure for taking a patient's blood pressure?
Person may be sitting or lying, with bare arm supported at heart level. - Palpate brachial artery; with cuff deflated, center it about 2.5 cm (1 in) above brachial artery and wrap it evenly. - Now palpate brachial or radial artery. - Inflate cuff until artery pulsation obliterated and then 20 to 30 mm Hg beyond. ■This will avoid missing an auscultatory gap, when Korotkoff sounds disappear during auscultation. - Deflate cuff quickly and completely; wait 15 to 30 seconds before reinflating so blood trapped in veins can dissipate. - Place bell of stethoscope over site of brachial artery, making a light but airtight seal. =Diaphragm endpiece usually adequate, but bell designed to pick up low-pitched sounds of blood pressure reading - Rapidly inflate cuff to maximal inflation level you determined. - Then deflate the cuff slowly and evenly, about 2 mm Hg per heartbeat. Note points at which you hear first appearance of sound, muffling of sound, and final disappearance of sound.
Which tone would the nurse expect to hear when percussing over the lungs? Tympany Dullness Resonance Flatness
Resonance
The nurse auscultates to obtain which assessment information? Select all that apply. Sounds produced by internal organs The sound of heart valves closing Expected movement of air or fluid through internal organs The temperature and texture of skin Distention or pulsation of the abdomen
Sounds produced by internal organs Auscultation involves listening to sounds produced by internal organs. The sound of heart valves closing Auscultation is used to identify the activity of the heart, such as heart valves closing. Expected movement of air or fluid through internal organs Auscultation involves listening to sounds caused by expected movement of air or fluid through internal organs. The temperature and texture of skin Auscultation will not assist in obtaining assessment information about the temperature and texture of skin. Palpation would assist in obtaining information about skin temperature and texture. Distention or pulsation of the abdomen Auscultation will not assist in obtaining assessment information about distention or pulsation of the patient's abdomen. Inspection would assist in obtaining information about distention or pulsation of the abdomen.
T/F: Inspection always comes first?
T: In all situations, inspection should be the first step, including an abdominal exam.
What is a general survey?
The general survey is a study of the whole person - Covers general health state and any obvious physical characteristics - Provides an overall impression - Includes objective parameters that apply to the whole body - Includes areas of physical appearance, body structure, mobility, and behavior
When does inspection begin?
The moment you first meet the person and develop a general survey
Which steps are required to conduct accurate inspection? Select all that apply. Turn off the lights to calm the patient Validate findings with the patient Expose the area being inspected Ensure adequate lighting is available Complete the inspection rapidly to save time
Turn off the lights to calm the patient Inspection requires adequate lighting to ensure accurate findings. Validate findings with the patient The nurse should validate inspection findings with the patient. Expose the area being inspected The nurse should expose the area being inspected. Ensure adequate lighting is available Adequate lighting (daylight or artificial) ensures accurate findings. Complete the inspection rapidly to save time Inspection should be completed carefully and unhurriedly.
Which tone would the nurse expect to hear when percussing over the stomach? Tympany Dullness Resonance Flatness
Tympany
The nurse would expect to hear which tones when percussing the patient's liver? Tympany Dullness Resonance Flatness
Tympany Tympany, a high-pitched drum-like sound, is heard over the gastric area, not the liver. Dullness Dullness, a soft high-pitched thudding sound, is heard over dense organs, such as the liver. Resonance Resonance, a low-pitched hollow sound, is heard over the lungs, not the liver. Flatness Flatness, a soft high-pitched sound, is heard over the bones or muscles, not the liver.
What is bimanual palpation?
Using both hands to capture an organ, e.g. pelvic exam-uterus, breast exam
Light palpation is best used to obtain which assessment data? Uterine firmness Moisture of skin Liver shape and size Distention of colon
Uterine firmness Bimanual palpation is required to assess the texture and firmness of some organs, including the uterus. Moisture of skin Light palpation is best for assessing texture, temperature, moisture, tenderness, pulsations, or superficial masses and lesions. Liver shape and size Deep palpation is best for assessing abdominal structures, particularly the liver. Distention of colon Deep palpation is best for assessing abdominal structures.
What are the parts of the stethoscope?
bell and diaphragm Diaphragm—flat edge, high pitched sounds (diaphragm is the bigger/wider side) ■Bell—deep, hollow cuplike shape, soft pitched sounds (the bell is the smaller side) ■Turnable diaphragms— allows you to listen to both high pitched and soft pitched sounds
What is blood pressure?
force of blood against vessel walls
What is the force of the pulse?
strength of heart's stroke volume (the amount of blood ejected by the heart in any one contraction)
How does heart rate fluctuate with heart rate?
■Heart rate varies with respiratory cycle, speeding up at peak of inspiration and slowing to normal with expiration. ■Inspiration momentarily causes a decreased stroke volume from left side of heart. ■To compensate, heart rate increases.○If any other irregularities are felt, auscultate heart sounds for a more complete assessment.
A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select ALL that apply). A. Apply 3-5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing.
●A. The Aps should apply alcohol rubs to DRY hands and we the hands FIRST before applying soap for handwashing. ●B. CORRECT: This is the amount of time it takes to remove transient flora from the hands. For soiled hands, the recommendation is 2 minutes. ●C. The Aps should use warm water to minimize the removal of protective skin oils. ●D. CORRECT: If the sink does not have foot or knee pedals, the AP should turn off the water with a clean paper towel and not with their hands. ●E. The Aps should dry their hands with a clean paper towel. This helps prevent chapped skin.
A nurse in a provider's office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of the skin temperature? A. Palmar surface B. Fingertips C. Dorsal surface D. Base of fingers
●A. The palmar surface of the hands is especially sensitive to vibration, not temperature. ●B. The fingertips are sensitive to pulsation, position, texture, size, and consistency, not temperature. ●C. CORRECT: The dorsal surface of the hand is the most sensitive to temperature. ●D. The base of the fingers is especially sensitive to vibration, not temperature.
T/F: Is it important to follow stated facility guidelines for monitoring in regard to vital signs?
●According to the powerpoint, nurses are to follow stated facility guidelines for monitoring.
What are some parts of physical appearance to assess during a general survey?
●Age: person appears his or her stated age ●Sex: sexual development appropriate for gender and age ●Level of consciousness: person alert and oriented, attends to your questions and responds appropriately ●Skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesion ●Facial features: symmetric with movement ●Overall appearance: provide general statement r/t presence or absence of distress
In the clinical setting, what factors are important to consider when speaking to a patient?
●Consider your emotional state and that of the person being examined. ●Measurement and vital signs. ●Maintain privacy and respect. ●Perform hand hygiene. ●Provide explanations. ●Summarize findings for person.
What are vital signs and what do they include?
●Data that is trended throughout patient experiences in multiple clinical practice settings ●Used in nursing judgment to warrant additional assessment. ●Include temperature, respiratory rate, pulse, and blood pressure
Identify some abnormalities of body weight and proportion?
●Dwarfism - Hypopituitary dwarfism - Achondroplastic dwarfism ●Gigantism versus acromegaly (hyperpituitarism) ●Anorexia nervosa ●Endogenous obesity—Cushing's syndrome ●Marfan syndrome
What are some parts of behavior to assess during a general survey?
●Facial expression: expressions appropriate to situation ●Mood and affect: person comfortable and cooperative with examiner and interacts pleasantly ●Speech: articulation (ability to form words) clear and understandable ●Dress: appropriate to climate, looks clean and fits body, and is appropriate to person's culture and age group ●Personal hygiene: person appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group
What are some parts of mobility to assess during a general survey?
●Gait: normally base is as wide as shoulder width - Foot placement: accurate; walk smooth, even, and well-balanced; and associated movements, such as symmetric arm swing, are present - Range of motion: note full mobility for each joint, and that movement is deliberate, accurate, smooth, and coordinated - No involuntary movement
What are doppler techniques and what situations would they be used in?
●In some situations, pulse and BP measurement is enhanced by using an electronic device, Doppler ultrasonic flow meter. ●Technique works by a principle that sound varies in pitch in relation to distance between sound source and listener: pitch is higher when distance is small, and pitch lowers as distance increases. ●In this case, sound source is blood pumping through artery in rhythmic manner. ●Handheld transducer picks up changes in sound frequency as blood flows and ebbs, and it amplifies them.
What are common errors in BP measurement?
●Leads to high readings -Taking when physiologically active, following activity, or emotionally labile -Narrow cuff size and/or applied too loose -Reinflating during procedure ●Leads to low readings -Decreased inflation -Too large cuff size ●Can lead to high or low readings—examiner/observer error -Position of arm or leg -Improper cuff size -Deflating cuff too quickly
What is the procedure of the Doppler technique?
●Listener hears whooshing pulsatile beat. ●Doppler technique is used to locate peripheral pulse sites. ●For BP measurement, Doppler technique augments Korotkoff sounds. ●Apply coupling gel to transducer probe. ●Turn Doppler flow meter on. ●Touch probe to skin, holding probe perpendicular to artery. ●A pulsatile whooshing sound indicates location of artery. ●May need to rotate probe, but maintain contact with skin. ●Do not push probe too hard or you will wipe out pulse. ●Inflate cuff until sounds disappear; then proceed another 20 to 30 mm Hg beyond that point. ●Slowly deflate cuff, noting point at which first whooshing sounds appear; this is systolic pressure.
What are some lifestyle modifications a nurse can recommend to a patient with HTN?
●Prevention and management -Weight loss -Limit alcohol use -Increase aerobic exercise activity pattern -Reduce sodium intake -Maintain adequate sources of dietary potassium, calcium and magnesium -Smoking cessation -Reduce intake of saturated fats and cholesterol
What is a pulse oximeter, how does it work, and what is considered normal SpO2?
●Pulse oximeter: a noninvasive method to assess SpO2 ●Sensor attached to person's finger has diode that emits light and detector measures relative amount of light absorbed by HbO2 and unoxygenated (reduced) Hb. ●Healthy person with no lung disease and no anemia normally has an SpO2 of 97% to 98%. -Select appropriate pulse oximeter probe. -Finger probe spring loaded and feels like clothespin attached to finger but does not hurt. -At lower oxygen saturations, ear lobe probe more accurate and less affected by peripheral vasoconstriction.
Describe pulse in regard to vital signs?
●Pulse: palpable flow felt in the periphery as a result of pressure wave generation from stroke volume - Rate and rhythm
What are some parts of structure to assess during a general survey?
●Stature: height appears within normal range for age, genetic heritage ●Nutrition: weight appears within normal range for height and body build; body fat distribution even ●Symmetry: body parts look equal bilaterally and are in relative proportion ●Posture: person stands comfortably erect as appropriate for age ●Position: description of patient's position during assessment
What are the downsides of utilizing a Temporal Artery Thermometer (TAT)?
●Takes multiple readings and produces average result
What are the differences in vital signs between young adults and aging adults?
●Temperature: changes in body's temperature regulatory mechanism leave aging person less likely to have fever but at greater risk for hypothermia -Temperature is less reliable index of older person's true health state; sweat gland activity is also diminished. ●Pulse: normal range of heart rate is 60 to 100 bpm, but rhythm may be slightly irregular -Radial artery may feel stiff, rigid, and tortuous in older person, although does not necessarily imply vascular disease in heart or brain. -Increasingly rigid arterial wall needs faster upstroke of blood, so pulse is actually easier to palpate. ●Respirations: aging causes decrease in vital capacity and decreased inspiratory reserve volume -You may note shallower inspiratory phase and an increased respiratory rate. ●Blood pressure: aorta and major arteries tend to harden with age -As heart pumps against a stiffer aorta, systolic pressure increases, leading to widened pulse pressure. -In many older people, both systolic and diastolic pressures increase, making it difficult to distinguish normal aging values from abnormal hypertension.
How to take temperature with a Tympanic membrane thermometer?
●Tympanic membrane thermometer (TMT) senses infrared emissions of tympanic membrane (eardrum). - Gently place covered probe tip in person's ear canal; temperature can be read in 2 to 3 seconds.
How to accurately take your patients weight?
●Use a standardized balance (more accurate) or electronic standing scale. ●Instruct person to remove his or her shoes and heavy outer clothing before standing on scale. ●When sequence of repeated weights is necessary, aim for approximately same time of day and same type of clothing worn each time. ●Record weight in kilograms and pounds. ●Show person how his or her weight matches up to recommended range for height (not applicable in all scenarios) ●Compare trends over time
What are the conversion equations between Celsius and Fahrenheit?
●Use this conversion - Degrees C = 5/9 (F − 32) - Degrees F = (9/5 ×C) + 32
How does a Temporal Artery Thermometer (TAT) work and how do you use it?
●Uses infrared emissions from temporal artery ●Sliding probe across forehead
How do you take a rectal temperature?
●Wear gloves and insert lubricated rectal probe cover on an electronic thermometer only 2 to 3 cm (1 in) into adult rectum, directed toward umbilicus. ■For a glass thermometer, leave in place for 2½ minutes (however glass thermometer are rare and should not be used due to their ability to break and contaminate with mercury) ■Disadvantages to rectal route are patient discomfort and time-consuming and disruptive nature of activity.
