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Fund. of Nursing

Focused Assessment

QuestionAnswer
Assessment Techniques 1. Inspection 2. Palpation 3. Percussion 4. Auscultation
Inspection Is the systematic and thorough observation of the client and specific areas of the body -Expose area -Look before touching -Use adequate lighting -Warm room for examinations
Palpation Is the assessing the characteristic s of an organ or body part by touching and feeling it with the hands or fingertips
Percussion Is tapping a portion of the body to determine if there is tenderness or to elicit sounds that vary according to the density of underlying structures
Auscultation Means listening with a stethoscope for normal and abnormal sound generated by organs and structures such as the heart/lungs/intestines/major arteries
Sounds of auscultation High-pitched/low-pitched/harsh/ blowing/crackling/loud/distant/ soft
The Interview Process 1. Introductory Phase 2. Working Phase 3. Summary and Closure Phase *Too Long* Timby PG. 35-38
Subjective vs. Objective -Subjective: statements the client makes about what he or she feels -Objective: are facts obtained through observation/physical examination/diagnostic testing
Open vs. Closed questions -Open: require discussion post-question -Closed: require only "yes" or "no" answers
Timing of the initial assessment *Too Long* Timby 34-35
Signs vs. Symptoms -Signs: measurable; of quantity -Symptoms: emotions/feelings of concern or discomfort
Methods of physical assessment *Too Long* Timby PG. 39
Proper methods to obtain vital signs *Too Long* Perry PG.72/80/84/89/95/102
Alterations in vital signs *Examine/review Pediatrics&Geriatrics* Perry PG. 67
Alterations in skin assessment findings *Too Long* Perry PG. 116-118
Alterations in lung assessment findings *Too Long* Perry 126 & 130
Rationale behind obtaining core body temperature The purpose of measuring body temperature is to obtain a representative average temperature of core body tissues. Perry PG. 68
Measuring Intake & Output *Too Long* Perry PG. 162
Alterations in musculoskeletal findings *Too Long* Perry 157-158/161
Considerations when examining older adults/children & adolescents *Too Long* Perry PG. 112
Alterations in breathing pattern *Too Long* Perry PG. 90
Alterations in pedal pulses *Too Long* Perry PG. 141
Alterations in cardiac assessment *Too Long* Perry PG. 132/137/139
Delegation of data collection to assistive personnel NAP-check in Perry & Potter PG. 68/79/83/87/92/100/102/112/120/125/132/143/149/154/162
Best positioning for assessments Degree/position will change depending on assessment. Perry & Potter (Assessment) PG. 73-76/80-81/84/89/95/103
Proper assessment technique for each area of the body Perry & Potter/Skills Assessment PG. 71/79/83/87/93/100
Created by: Megan123456
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