NR302 Health Assessment Exam 2 Review

Exam 2 Review Assessment Techniques - Inspection- concentrated watching; begins when 1st meet the patient; always comes 1st - Palpation- sense of touch (texture, temperature, moisture, organ location/size, swelling, vibration, pulsation - Percussion- tapping the persons skin w/ short, sharp strokes to assess underlying structures - Stationary hand- hyperextend middle finger and place its distal joint and tip firmly against the persons skin - Striking hand- middle finger of dominant hand; scan muscles to make sure they are steady but not rigid - Production of sound- amplitude (intensity), pitch (frequency), quality (timbre), duration (length) - Auscultation- listening to sounds prod by the body (heart and BV, lungs and abdomen) • Diaphragm- high pitch (breath, bowel, normal heart) • Bell- soft, low pitch (extra heart sounds, murmurs) - Never listen through a gown - Never listen over bone - Correct equipment - Safe environment- hand hygiene before and after encounter Chapter 12- Skin, Hair, Nails - Vellus hair- covers most of the body - Terminal hair- scalp, eyebrows, pubic area, axillae, face, chest - Sebaceous glands- prod sebum; lubricates skin and hair, everywhere except palms and soles; most abundant in scalp, forehead, face, chin - Sweat glands- eccrine (sweat), apocrine (thick, milky; axillae, genitals, nipples) Subjective Assessment - History of skin disease? - Change in pigmentation? - Change in mole? (color, size, shape, tenderness, itching) - Excessive dryness/moisture? - Pruritus? (itching) - Excessive bruising? - Rash/lesions? - Medications? - Hair loss? - Change in nails? - Env or occupational hazards? - Patient centered care- assess self-care and hygiene - Pooling = sitting at the bottom