ch 8 assessment techniques andsafety in the clinical settings

120 vocabulary-style flashcards covering key concepts, equipment, techniques, infection control, pediatric development, and patient positioning from the lecture notes.

Inspection

Concentrated watching; initial general survey of the patient and each body system.

Palpation

Using touch to assess texture, temperature, moisture, organ size/location, tenderness, pulsation, and masses.

Percussion

Tapping the body's surface to elicit notes that indicate location, size, and density of underlying structures.

Auscultation

Listening to body sounds with a stethoscope; requires a quiet environment and proper technique.

General survey

Overall impression from appearance, behavior, and movement observed at first encounter.

Symmetry

Comparison of right and left sides; the body is nearly symmetric and serves as its own control.

Lighting

Quality, exposure, and tangential lighting used to visualize data during examination.

Otoscope

Instrument to visualize the ear canal and tympanic membrane; uses multiple specula sizes.

Ophthalmoscope

Instrument to view internal eye structures and fundus; uses lenses/mirrors.

Nasal speculum

Speculum used to view the nasal cavity.

Vaginal speculum

Speculum used to view the vaginal canal and cervix.

Stethoscope

Instrument to hear heart, lung, and bowel sounds; has diaphragm and bell endpieces.

Diaphragm

Stethoscope endpiece best for high-pitched sounds; pressed firmly on skin.

Bell

Stethoscope endpiece best for soft, low-pitched sounds; held lightly against skin.

Tun able diaphragm

Endpiece that allows listening to both low- and high-frequency sounds without rotating.

Pleximeter

Stationary finger used in percussion, pressed against the skin.

Plexor

Dominant hand's striking finger used to percuss the pleximeter.

Stationary hand

The hand that remains against the patient during percussion.

Striking hand

Dominant hand's middle finger used to strike; wrist action is key.

Percussion note

Audible vibration produced by percussion, indicating underlying structure.

Resonant

Loud, low-pitched note typical of air-filled structures.

Hyperresonant

Even louder than resonant; often overexpanded air spaces.

Tympany

Drum-like sound over air-filled viscera (e.g., stomach, intestines).

Dull

Soft, muffled note over denser organs (e.g., liver, spleen).

Amplitude

Loudness or intensity of a percussion note.

Pitch

Frequency of vibration; high vs low tones.

Quality

Timbre; distinctive sound color produced by overtones.

Duration

Length of time the percussion note lingers.

Air-filled structure

Structures containing air produce louder, deeper, longer sounds.

Dense structure

Solid or dense organs produce softer, higher, shorter sounds.

Light palpation

Gentle initial palpation to detect surface characteristics.

Deep palpation

Palpation with deeper, intermittent pressure to assess deeper structures.

Warm hands

Warming hands before palpation to improve comfort and sensitivity.

Relaxation techniques

Imagery or slow breathing to help patient relax during palpation.

Bimanual palpation

Using both hands to envelop or capture a body part for precise delimitation.

Crepitation

Crackling sensation or sound from air in tissues or joints.

Pulsation

Rhythmic beating felt from vessels or heart when palpating.

Vibration

Feel or hear vibrations indicating tissue density during palpation.

Temperature (palpation)

Assess skin temperature to detect abnormal warmth or coolness.

Texture

Surface feel of skin or tissue assessed during palpation.

Moisture

Presence of moisture or dryness on the skin relevant to exam.

Tenderness

Pain elicited on palpation indicating possible inflammation or injury.

Lumps

Small palpable masses detected during palpation.

Masses

Larger discrete lumps or growths found on examination.

Organ location

Identification of where an organ lies within the body.

Organ size

Assessment of how large an organ is, relative to expected size.

Surface characteristics

Texture, contour, and surface irregularities detected by touch.

Reflex hammer

Instrument used to elicit deep tendon reflexes during exam.

Monofilament

Thin filament used to test sensory function in the feet.

Otoscope specula

Five sizes of specula used to fit different ear canals.

Otoscope head

Head that attaches to the otoscope base; provides illumination.

Aperture

Opening on the ophthalmoscope used to select viewing area.

Lens selector

Dial on the ophthalmoscope to adjust focus via diopters.

Lens indicator

Number indicating the current lens strength on the ophthalmoscope.

Diopter

Unit of lens strength; positive for farsighted, negative for nearsighted.

Pediatric endpieces

Child-sized attachments for stethoscope and otoscope.

Developmental competence

Assessment approach that accounts for growth patterns and behavior stages.

Infant

Newborn to 12 months; Erikson task is establishing trust.

Neonate

Newborn infant; first life stage often used interchangeably with infant.

Moro reflex

Startle reflex in infants, typically assessed toward end of exam.

Autonomy

Erikson stage for toddlers emphasizing independence.

Initiative

Erikson stage for preschoolers emphasizing planning and doing.

Industry

Erikson stage for school-age children emphasizing competence.

Identity

Erikson stage of adolescence focusing on self-identity formation.

SMR (Sexual Maturity Rating)

Pubertal staging used to describe physical development.

Wong's Essentials of Pediatric Nursing

Reference text for pediatric assessment and communication.

Preschool cooperation

Preschoolers are usually cooperative; use games and explanations.

Paper doll demonstration

Paper-outline activity to engage a child during exam.

Toddler positioning

Sitting on caregiver’s lap; knee-to-knee positioning for exam.

Security object

Blanket or teddy bear used to comfort young children.

Caregiver involvement

Engage caregiver to facilitate pediatric examination.

Nonverbal cues

Using signals other than words to guide pediatric interactions.

Least distressing steps first

Begin with noninvasive, nonthreatening parts of exam.

Privacy (pediatrics)

Maintain privacy with draping and caregiver presence as appropriate.

Privacy draping

Covering patient appropriately to maintain modesty.

Adolescent privacy

Examine the adolescent alone when possible to discuss health.

Aging adult adaptation

Adjust pace, allow rest, and use physical touch to compensate for senses.

Sick person approach

Adapt examination order and position to distress level; collect mini-database first.

Head-to-toe sequence

Systematic examination order from head to toe.

High Fowler

Sitting position with upper body elevated to ~60 degrees.

Semi-Fowler

Partial sitting position with elevated head of bed.

Lithotomy

Supine position with hips and knees flexed for pelvic exams.

Side-lying

Lateral recumbent position; useful for back and posterior exams.

Modified left lateral recumbent

Left-side lying position; facilitates certain organ examinations.

Prone

Face-down position; used for posterior surface examination.

Supine

Lying flat on back; common starting position for exams.

Dorsal recumbent

Supine with legs extended; used for abdominal or pelvic exams.

Privacy and draping

Ensure modesty by draping exposed areas separately.

Preparation (developmental stages)

Tailor explanation and approach to the child’s developmental level.

Gown and drape

Use gown and draping to maintain modesty during exam.

Sequence (developmental stages)

Progression from infant to adolescent when assessing a child.

Caregiver reassurance

Provide supportive statements to comfort anxious patients.

Tactile communication

Using touch respectfully to convey empathy during exam.

Privacy in hospital settings

Maintain patient confidentiality and privacy in care settings.