Assessment Techniques
Part of the stethoscope used to auscultate soft, low pitched sounds such as extra heart sounds or murmurs.
What is the bell endpiece?
Order of performing GI assessment
Inspect, Auscultate, Percuss, Palpate
Valve best heard to 2nd intercostal space right sternal border
Aortic
Normal size of pupils
3-5 mm
Name for a linear crack with abrupt edges that extends into the dermis
What is a fissure?
Four skills used when performing a physical examination
Inspection, palpation, percussion, and auscultation
Number of bowel sounds heard per minute normally
5-30
Phase of the cardiac cycle when the ventricles relax and fill with blood
Diastole
What you observe if you note a hump or shelf when looking in nasal cavity.
What is a deviated septum?
Stage of Pressure Injury where the skin is intact. There is localized redness but it doesn't blanch
Stage I Pressure Injury
Standard precautions apply to all patients. Components include hand hygiene, use of PPE, and respiratory hygiene/cough etiquette. When is it imperative that gloves be worn?
When you anticipate contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin.
Organ found in Right Upper Quadrant of abdomen. (name one)
liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal, hepatic flexure of colon, part of ascending and transverse colon
Name for a palpable vibration
Thrill
Tonsil grade when they are touching the uvula
What is 3+?
Name for audible and palpable crunching or grating that may accompany movement of joints
What is crepitus?
Components of PQRST method of pain assessment
P- provocation/palliation
Q- quality/quanity
R- region/radiation
S- severity scale
T- timing
Client has orange urine. Identify one potential cause.
Medication side effect, foods/food dye, laxatives, dehydration, jaudice
Patient has loud, low pitched bubbling and gurgling sounds that start in early inspiration and may be present in expiration. These sounds may decrease by suctioning or coughing.
What are course crackles?
When is performing Romberg test this is evaluated.
What is balance?
Postural change sometimes seen in older adults that presents as increase in thoracic curve
What is kyphosis?
Four main components of mental status exam
Appearance, behavior, cognition, thought process
This is found in stool of patient with steatorrhea.
Fat
Radial and Ulnar
3 items assessed when using the Glasgow Coma Scale
Eye opening response
Motor response
Verbal response
Name for tiny hemorrhages, 1-3 mm, that are round and discrete; may be dark red, purple, or brown in color.
What are petechiae?