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Health

Assessment

QuestionAnswer
How is a Complete Assessment conducted? head-to-toe
What is Inspection? visual examination
What is Palpation? examination of the body using the sense of touch; light & deep palpation
What is Light Palpation? press gently w/ fingers moving hand in a circle
What is Deep Palpation? palpating w/ two hands
How is Deep Palpation done? put nondominant hand over the dominant pressing w/ fingers
On what pt is the Deep Palpation not done to? pt w/ acute abdominal pain / not yet diagnosed
What is Dorsal Recumbent? back lying w/ knees flexed & externally rotated
What is Supine? back lying w/ legs extended (straight)
What is Sitting? back straight & legs hanging freely
What is Lithotomy? back lying w/ feet supported on stirrups; hips should be in line w/ edge of table
What is Sims? side lying w/ lowermost arm behind body, uppermost leg flexed at hip & knee, uppermost arm flexed at elbow & shoulder
What is Prone? lies on abdomen w/ head turned to the side
What is Percussion? striking the body surface elicits sounds that can be heard / vibrations that can be felt; indirect & direct percussion
What is Direct Percussion? nurse strikes the area to be percussed w/ finger / fingers; strikes are rapid & movements of the wrist
What is Indirect Percusion? stricking the body w/ an object (ex. finger)
Percussion S & T: What is Flatness? dull / soft sound produced by very dense tissue (ex. muscle, bone)
Percussion S & T: What is Dullness? medium thudlike sound produced by dense tissue (ex. liver, spleen, heart)
Percussion S & T: What is Resonance? loud hallow sounds produced by lungs filled w/ air
Percussion S & T: What is Hyperresonance? not produced in a normal body, booming & can be heard over an emphysematous lung
Percussion S & T: What is Tympany? lound musical / drumlike sound produced form an air filled stomach
What is Auscultation? listening to sounds produced within the body; indirect & direct auscultation
What is Indirect Auscultation? use of an unaided ear; sounds that can be heard with the naked ear
What is Direct Auscultation? use of an stethoscope; transmits sounds to the nurse's ear
What does Pitch mean? frequency of vibrations (number of vibrations per second)
What does Intensity mean? loudness or softness of a sound
What does Duration mean? length of a sound (short/long)
What does Quality mean? subjective description of a wound (ex.whistling, gurgling, snapping)
The appearance/mental status can be assessed by an unlicensed personnel? false
The pt should be weighed at the same time each day w/ same clothes, and same scale? true
What does Hyperhidrosis mean? excessive perspiration
What does Bromhidrosis? foul-smelling perspiration
What does Pallor mean? deficiency of color in the face (paleness)
What causes Pallor? inadequate circulating blood/hemoglobin & reduction in tissue oxygenation; absence of red tones in skin & mostly seen in buccal mucosa
Pallor in brown skinned pt appears? yellowish brown tinge (slight shade/stain)
Pallor in black skinned pt's? may ashen gray
Where is Pallor in all people seen? conjunctiva,oral mucosa,nail beds,palms of hand,soles of feet
What does Cyanosis mean & what causes it? a bluish/purplish discoloration; deficient oxygenation of the blood
Where is Cyanosis more evident? nail beds,lips,buccal mucosa
Where is Cyanosis evident in dark skinned pt's? close inspection of pelpebral conjunctiva (lining of eyelids),palms-hands, soles-feet
What does Juandice mean? yellowish tinge (slight shade/stain)
Jaundice is evident? scela (white outer part) of the eyes, then mucous membranes,skin
If jaundice is suspected in dark-skinned pt's? inspect the posterior part of the hand palate for yellowish skin tone
Created by: JoannMejia
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