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Rasmussen College
Once you can recognize normal sounds, you can distinguish the abnormal sounds and "extra" sounds
Ch. 8 - ANSWERAssessment Techniques and Safety in the Clinical Setting
Health history provides - ANSWERSubjective data for health assessment
Objective data (the signs perceived by examiner through physical examination)
Skills performed one at a time, in this order: - ANSWERInspection
Palpation
Percussion
Percussion - ANSWERTapping person's skin with short, sharp strokes to assess underlying structures
Percussion has following uses:
Mapping location and size of organs
Signaling density of a structure by a characteristic note
Detecting a superficial abnormal mass
Percussion vibrations penetrate about 5 cm deep
Wash your hands—this is the single most important step to decrease microorganism transmission -
ANSWERBefore and after physical contact with each patient
After inadvertent contact with blood, body fluids, secretions, and excretions
, After contact with any equipment contaminated with body fluids
After removing gloves
Question
The nurse is preparing to do a physical assessment on a patient who is end-stage HIV positive. What
should the nurse do for self-protection?
1. Wash hands and don gloves, gown, and protective face shield.
2. Don gloves and wash hands after examination; no other protective equipment is necessary.
3. Wash hands and don two pairs of gloves and gown.
4. Wash hands, don gloves, and wash hands after examination; no other protective equipment is
necessary. - ANSWER4. Wash hands, don gloves, and wash hands after examination; no other protective
equipment is necessary.
Auscultation
Inspection - ANSWERClose, careful scrutiny, first of individual as a whole and then of each body system
Begins when you first meet person with a general survey
As you proceed through examination, start assessment of each body system with inspection
Inspection always comes first
Inspection requires
Good lighting
Adequate exposure
Occasional use of instruments, including otoscope, ophthalmoscope, penlight, or nasal and vaginal
specula, to enlarge your view
Palpation - ANSWERPalpation applies sense of touch to assess the following: