Chapter 8: Assessment Techniques and Safety in the Clinical Setting slides

VOCABULARY flashcards covering assessment techniques and safety in the clinical setting.

Senses used in physical examination

The four senses—sight, smell, touch, and hearing—used to obtain data during assessment.

Assessment sequence

The order of techniques: inspection, palpation, percussion, and auscultation.

Inspection

Visual examination of the patient, beginning with general survey and continuing through the body systems; requires good lighting and exposure.

General survey

The initial overall impression of the patient’s health, appearance, and behavior.

Adequate exposure

Sufficient exposure of the body parts to allow proper inspection.

Lighting

Quality and amount of light used during the examination.

Instruments in inspection

Tools such as otoscope, ophthalmoscope, penlight, and specula used during inspection.

Palpation

Use of touch to assess texture, temperature, moisture, location, size, swelling, masses, and tenderness.

Texture

Surface feel of skin or tissue as palpated.

Temperature (palpation)

Heat level of skin or tissue as felt by touch.

Moisture

Presence of moisture or dryness on the skin.

Organ location

Approximate position of an organ within the body.

Size (palpation)

Dimension or extent of an organ or mass.

Swelling

Edema or enlargement of tissue or an organ.

Vibration

Pulsatile or tremulous movement felt on palpation.

Crepitation

Cracking or grating sensation heard or felt under palpation.

Rigidity

Stiffness of tissue from disease or inflammation.

Spasticity

Increased muscle tone causing stiffness and restriction of movement.

Lumps or masses

Abnormal palpable lumps or masses detected during palpation.

Tenderness

Pain on palpation suggesting inflammation or injury.

Pain

Unpleasant sensory and emotional experience with tissue damage or potential damage.

Light palpation

Gentle initial palpation to assess surface characteristics.

Deep palpation

Firm palpation to evaluate deeper organs and structures.

Bimanual palpation

Palpation using both hands to assess larger organs or structures.

Fingertips

Fingers used for fine tactile discrimination and surface texture.

Fingers and thumbs

Digits used to assess position, shape, and consistency of an organ or mass.

Dorsa (back) of hands

Back of the hands used to assess temperature; skin here is thinner.

Ulnar surface of hand

Ulna side of the hand used to detect vibration.

Percussion

Tapping to assess underlying structures and identify location, size, and density.

Pleximeter

Stationary finger or hand placed on the body to receive percussion sounds.

Plexor

Striking finger that delivers percussion.

Percussion depth (≈5 cm)

Percussion notes typically reflect structures up to about 5 cm beneath the surface.

Density (percussion)

The percussion note indicates the density of underlying tissue.

Superficial mass (percussion)

A mass near the surface detected by percussion.

Pain elicitation (percussion)

Percussion may elicit pain if underlying structure is inflamed.

Deep tendon reflex (percussion)

Reflexes elicited using a percussion hammer.

Stationary hand

The pleximeter hand held steady on the skin during percussion.

Striking hand

The plexor hand that strikes to produce the percussion sound.

Pleximeter contact point

Only the distal joint and tip of the stationary finger touch the skin.

Plexor contact method

The striking finger makes contact with the body surface.

Amplitude

Loudness or intensity of a percussion or other sound.

Pitch

Frequency or tone of the sound.

Quality (timbre)

Character or color of the sound.

Duration

Length of time the sound lingers.

Air content effect on sound

Structures with more air produce louder, deeper sounds.

Dense structure effect on sound

Denser tissues produce softer or higher-pitched sounds.

Stethoscope function

In auscultation, it blocks extraneous sounds rather than magnifying them.

Diaphragm

Flat-edge part of a stethoscope for high-pitched sounds.

Bell

Cuplike part of a stethoscope for soft or low-pitched sounds.

Turnable diaphragms

Diaphragms that can be adjusted to hear both high- and low-pitched sounds.

Eliminate extra noise

Minimize ambient sounds during auscultation.

Warm environment (auscultation)

Keep the exam room comfortable to aid patient relaxation.

Warm stethoscope

Warming the stethoscope before use to improve patient comfort.

Hairy areas (auscultation)

Avoid placing the stethoscope on hairy regions to improve contact.

No listening through gown/clothes

Do not auscultate through clothing or gown.

Artifact (auscultation)

Unwanted sounds from equipment or environment that distort findings.

Clean field

Designated clean area for handling equipment before use.

Alcohol wipe

Disinfect stethoscope with alcohol before and after use.

Clean vs used area

Separate zones for clean and used equipment.

Examination room environment

Room should be warm, comfortable, quiet, and well lit.

Lighting choices

Natural or tangential lighting preferred for exams.

Exam table positioning (45 degrees)

Position the table to allow easy access and head elevation of about 45 degrees.

Roll-up stool

Portable stool used when a seated position is needed.

Standard equipment

Core tools required for a screening physical examination.

Platform scale

Scale with height attachment used for measuring weight and height.

Sphygmomanometer

Blood pressure cuff and manometer for measuring BP.

Thermometer

Instrument to measure body temperature.

Pulse oximetry

Device to measure oxygen saturation in the blood.

Hand hygiene

The single most important step to reduce infection spread.

Protective equipment (PPE)

Gloves, mask, eye protection or face shield used to prevent exposure.

Otoscope

Instrument to examine the ear canal and tympanic membrane.

Ophthalmoscope

Instrument to inspect internal structures of the eye.

Penlight

Small flashlight used to illuminate areas and assess pupillary response.

Pocket vision screener

Portable tool for quick vision testing.

Skinfold calipers

Device to measure skinfold thickness for body composition.

Skin marking pen

Pen used to mark landmarks on the skin during exams.

Tuning fork

Fork used to test hearing and vibration sense.

Nasal speculum

Instrument to widen the nasal passages for examination.

Tongue depressor

Wooden stick used to depress the tongue during oral exam.

Cotton balls

Cotton balls used for cleaning or sample collection.

Flexible tape measure

Tape used to measure body dimensions and circumferences.

Ruler

Straightedge used for linear measurements.

Sharp object (split tongue valve)

Sharp instrument used for specialized procedures; handle with care.

Reflex hammer

Hammer used to elicit deep tendon reflexes.

Bivalve vaginal speculum

Speculum used for gynecologic examination to visualize the cervix.

Cytology materials

Materials used to collect samples for cytologic analysis.

Lubricant

Lubricant used to facilitate insertion of specula or procedures.

Fecal occult blood materials

Reagents used to test for hidden blood in stool.

Specula sizes

Five different sizes of specula to fit patient anatomy.

Otoscope specula

Various tip sizes for the otoscope.

Ophthalmoscope aperture

Setting that controls light and viewing angle on the ophthalmoscope.

Diopter

Power setting on an ophthalmoscope for focusing.

Otoscope base power source

The base unit provides illumination for the otoscope.

Clean field policy

Procedures to maintain a clean field and prevent contamination.

Nosocomial infections

Infections acquired in a hospital or healthcare setting.

MRSA

Methicillin-resistant Staphylococcus aureus, a resistant bacteria.

VRE

Vancomycin-resistant Enterococcus, a resistant organism.

Multidrug-resistant tuberculosis

TB resistant to multiple antimicrobial drugs.

Handwashing steps

The sequence of actions—before/after patient care, after exposure to body fluids, after contact with equipment, after removing gloves.

Standard precautions

Basic infection-control practices applied to all patients.