NURS 190 Physical Assessment Study Guide Quiz 1

NURS 190 Physical Assessment Study Guide Quiz 1 NURS 190 Physical Assessment Study Guide Quiz 1 PA SG 1 ABD assessment: Inspect Auscultate Percuss Palpate Light Palpation: skin texture, pulse, tenderness inflamed area (finger pads 1cm) Moderate Palpation: depth, size, shape, consistency, mobility of organs, pain, tenderness, pulsations (palmar surface of fingers 1-cm) Deep Palpation: Body cavities, musculature thick, tense, rigid, or obese (palmar of dominant over non-dominant 2-4cm) • Access temperature w/ dorsal part of hand (most sensitive) • Blood percussion — Ulnar surface of hand Tympany: Loud — High pitch Drum like, Filled w/ air, gastric bubble, organs filled w/ air Resonance: Loud — Low-pitch tone, Hollow Hyper-resonance: Loud-Low tone, Long Duration Air trapped in the lungs Dullness: High-Pitch, Short and Soft, Over solid organs Liver, Stool filled colon Flatness: High-pitch, soft, short (muscle, bone) Stethoscope: bell= murmurs/low-frequency, diaphragm=bowel sounds, etc. Skin turgor: Old Pt. check under the clavicle 3- is normal Ulcer stage 1: non-blanching Ulcer Stage 4: sepsis to bone can lead to osteomyelitis, bone or muscle visible Unstageable: black or purple, can be cause of deep tissue injury