Assessment
What are the 4 techniques used in assessment?
what body area is there a difference? and what is that difference?
- inspection, palpation, percussion, auscultation
- abdomen (GI): Inspection, Auscultation, Percussion, Palpation.
What are the main area of questions you ask patient's to elicit information?
- subjective
- objective
- focused/ health interview
What is a normal Tympanic membrane in appearance with an otoscope?
Pearly/Clear (translucent) or Gray in color. No scarring or redness or swelling. If present indicate infection.
occurs during expiration, audible, high pitch whistling sound. seeing in patients with asthma or obstruction.
Wheezing or Wheezes
Examination used to test vision and give an example of a vision reading and what it means
- Snellen Chart
- 20/40, 20/80, etc
the patient can read at (top number) feet what a person with good vision can read normally (bottom number) feet.
In patients with darker skin, where can you assess for jaundice?
around mouth, mucous membranes, conjuctivae, palms,sclera.
how can you set yourself up for a successful assessment?
- be prepared
- have inviting environment (temp, table, equipment)
- guardian if underage
- give patient time to answer questions
- stop if patients ask you too or they are uncomfortable
Where do you find the Point of Maximum Impulse (PMI)?
5th intercostal space at midclavicular line.
Pitting edema is graded in mm and what are those ranges?
+1=2mm
+2=4mm
+3=6mm
+4=8mm
What does the Weber test measure? and how you examine this in your patient?
testing sound in both ears at the same time.
activate tunning fork and place at top of head (midline), ask patient to state if they can hear sound equally in both ears or state any abnormal findings.
Tapping the body part to elicit a sound or vibrations is called what
Percussion
what does the Glasgow coma scale measure
level of consciousness. There are 3 categories.
- response to motor, verbal, eye,
What does PERRLA stand for?
Pupils Equal Round Reactive Light Accommodating.
what is the name of the vibrations palpation of the patient's chest when they are asked to say "99"
tactile fremitus
What does the Rinne test measure?
How is it performed on your patient?
- measure air and bone conduction
- activate tunning fork and place at the patient's ear and mastoid bone.
which artery should you not palpate at the same time
carotid pulse to prevent lack/lost of oxygen supply to the brain.
open-ended questions do what? give an example
closed-ended questions do what? give an example
open ended allow more elaboration of the question asked, more details.
closed ended are answered shortly usually in a yes and no manner.
Range of Motion (ROM): Difference between Adduction vs Abduction
Adduction is to move the body part closer toward the center of the body or decrease the distance between the 2 points
Abduction is to move the body part away from the center of the body or increase the distance between the 2 points.
if a pulse is difficult to palpate, what is the next step
use a doppler or ultrasound
How do you assess the Romberg Test?
have the patient stand with feet together, eyes closed, arms to the side for about 20 seconds and assess for any swaying or staggering.
keep in mind patient's safety. use this assessment for fall risk.
how to assess a patient's level of strength?
what is the rating or levels?
ask the patient to squeeze your hands
press against your hands with their feet
resist you pushing down on their shoulders
ratings from 0-5 (5 levels)
Term used when one side is the same as the other in regards to shape, size, and position. Usually documented when inspecting the patient body during assessment.
what is symmetry. equal sides.
usually non-palpable. use the pads of the fingers in a circular motion.
collapse lung from either trauma or lung rupture. Movement on 1 side of the lung is termed____
pneumothorax
Breast exam assessment
better to perform sitting upright
must have symmetry unless mastectomy
BSE performed monthly
techniques: inspection and palpation. use circular motion and pads of first 3 fingers.