inspection - Answers - looking at the patient as a whole
- each body system
Palpation - Answers examine by touching, includes pulses,
Percussion - Answers Tapping on the skin - nurses do not do
Ausculation - Answers listening to the sounds of the stethoscope
Diaphragm of stethoscope - Answers flat endpiece of the stethoscope used for hearing relatively high-
pitched heart sounds
Bell of stethoscope - Answers cup-shaped end piece used for soft, low-pitched heart sounds. smaller
circle
Nosocomial - Answers hospital acquired infection
The infant - Answers -Do not use head to toe approach
-Never leave unattended
-parents hold as much as possible
- do less invasive assessment 1st
Toddler - Answers -Keep items out of reach
-parents hold
Preschool child - Answers -Ask if child wants to sit on exam table or parent's lap
-If appears resistant do more invasive items last
assessing older adults - Answers -Rest period
-Minimize position changes
temperatrue range - Answers 96.8 to 100.4
What is considered a fever? - Answers 100.4 or higher
What are the factors affecting temperature? - Answers Age, exercise, hormone levels, circadian rhythm,
stress, environment
when do temps drop? - Answers during night , stress, and environment
, What are the sites you can take temperature? - Answers Oral, Rectal, Axilla(underarm), Tympanic,
Temporal, core (urinary cath and central lines)
Pulse sites - Answers Apical, Radial
What pulse site is most accurate? - Answers Apical
What pulse site is most common? - Answers Radial
How many beats per min is Tachycadia? - Answers >100 beats/min
How many beats per min is Bradycardia? - Answers <60 beats/min
regular pulse count - Answers 30sec then times by 2
irregular pulse count - Answers count full minute
respirations - Answers - Full Inspiration and Expiration = 1 breath
- Do not let pt know you are counting
factors influencing respiration's - Answers · Exercise
· Pain
· Anxiety
Smoking
peds respirations - Answers - Have irregular rhythm, count full minute
- 10-15 sec period of apnea
- See more movement on abdomen
- Sleeping most accurate
What are the factors influencing BP? - Answers Age (up as we age) , Stress, Ethnicity(African american =
hypertension), Medication, Activity & weight, smoking
What is a normal Blood pressure? - Answers 120/80
What is elevated blood pressure? - Answers 120-129/below 80
What is stage 1 blood pressure? - Answers 130-139/80-89
What is stage 2 blood pressure? - Answers 140 or higher/ 90 or higher
Hypotension - Answers Systolic < 90