NURS-1037 – Vital Signs

Physical examination skills are ____, ____, ____, and ____

inspection, palpation, percussion, auscultation

The correct order to perform physical examination skills is ____, ____, ____, and ____

inspection, palpation, percussion, auscultation

The order of examination skills is altered for the ____, where ____ is performed before ____

abdomen, auscultation, palpation

Using senses of sight, smell, touch, and hearing to gather data is known as ____

Cultivating your senses

____ is defined as concentrated watching or close scrutiny

Inspection

During inspection, first inspect the person as a ____, then move to ____

whole, individual body systems

To ensure symmetry during inspection, compare the patient’s ____ and ____ sides

right, left

Instruments used for inspection include the ____, ____, and specula (vaginal, nasal)

otoscope, ophthalmoscope, penlight

____ uses the sense of touch to confirm findings noted during inspection

Palpation

Palpation should be performed in a ____ and ____ manner

slow, systematic

Two types of palpation are ____ and ____

light, deep

Palpation techniques include applying ____ pressure and ____ palpation

intermittent, bimanual

Characteristics assessed by palpation include ____, ____, ____, organ location and size, and swelling

texture, temperature, moisture

Additional palpation characteristics include vibration or pulsation, rigidity or spasticity, ____, and presence of ____ or ____

crepitation, lumps or masses, tenderness or pain

The ____ are best for fine tactile discrimination, such as skin texture, swelling, pulsation, and lumps

fingertips

A ____ action of fingers and thumb is used to detect position, shape, and consistency of an organ or mass

grasping

The ____ of hands and fingers are best for determining temperature

dorsa (backs)

The ____ of fingers (metacarpophalangeal joints) or ____ surface of the hand are best for detecting vibration

base, ulnar

____ is the technique of tapping the skin with short, sharp strokes to assess underlying structures

Percussion

Percussion penetrates approximately ____ cm

5

Percussion yields palpable ____ and characteristic ____

vibrations, sounds

Percussion determines location and size by exploring edges and noting changes in the ____

note

Percussion determines density of underlying organs because air, fluid, and solid structures produce different ____

notes

Percussion can also yield ____ or tendon ____

pain, reflexes

In ____ percussion, the striking hand contacts the body wall directly

direct

In ____ percussion, the striking hand (plexor) hits the distal interphalangeal joint of the stationary hand (pleximeter)

indirect

Five characteristics of percussion notes are ____, ____, ____, ____, and ____

resonant, hyperresonant, tympany, dull, flat

Four features that vary among percussion notes are ____, ____, ____, and ____

amplitude, pitch, quality, duration

A percussion note that is medium-loud, low pitch, clear/hollow, and of moderate duration is ____

resonant

Resonant percussion is normally found over ____ tissue

normal lung

A percussion note that is louder, lower pitch, booming, and longer duration is ____

hyperresonant

Hyperresonant percussion is normal over a child’s ____ and abnormal in adults with air, such as ____

lungs, emphysema

A percussion note that is loud, high pitch, musical/drum-like, and sustained longest is ____

tympany

Tympany is found over an ____-filled viscus such as the stomach or intestine

air

A percussion note that is soft, high pitch, muffled thud, and short duration is ____

dull

Dull percussion is found over a relatively ____ organ such as the liver or spleen

dense

A percussion note that is very soft, high pitch, dead stop of sound, and very short duration is ____

flat

Flat percussion is found when ____ is absent, such as over thick muscle, bone, or tumor

air

____ uses the sense of hearing to detect sounds produced by the heart, blood vessels, lungs, and abdomen

Auscultation

The ____ of a stethoscope is best for high-pitched sounds like breath, bowel, and normal heart sounds

diaphragm

The ____ of a stethoscope is best for soft, low-pitched sounds like extra heart sounds and murmurs

bell

To eliminate artifacts during auscultation, remove sounds from ____, ____, ambient noise, and tubing friction

hair, clothing

The clinical setting/context of care may include the patient’s ____, clinic, or hospital

home

The examination room should be ____, comfortable, quiet, private, and ____

warm, well lit

The examination table should allow access to ____ sides of the body

both

A platform scale, sphygmomanometer, and stethoscope are examples of examination ____

equipment

Other equipment includes a ____, pulse oximeter, flashlight or penlight, otoscope/ophthalmoscope, and nasal speculum

thermometer

The ____ funnels light into the ear canal and onto the tympanic membrane

otoscope

The otoscope is used to assess for infection, debris, injury, or ____

malformations

The ____ illuminates internal eye structures for viewing the fundus through the pupil

ophthalmoscope

The ophthalmoscope has multiple ____ and aperture settings to correct for myopia or hyperopia

lenses

A stethoscope should be cleaned with a ____ between patients

sani-wipe

All equipment carried between patients should be cleaned with a hospital-approved ____

disinfectant

Proper ____ reduces the hazard of nosocomial (hospital-acquired) infections

handwashing

Routine practices and transmission-based precautions (contact, droplet, airborne, vectorborne) are guidelines published by the ____

Public Health Agency of Canada (2012)

In the clinical setting, always consider the patient’s and examiner’s ____ state

emotional

Hands-on practice includes measuring height, weight, and ____, and checking visual acuity

vital signs

The general approach should include brief ____ throughout the exam

health teaching

For infants, include parental presence, use ____, and perform the ____ distressing aspects first

distraction, least

For toddlers, perform the exam on the parent’s ____, use security objects, encourage ____, and demonstrate on the ____ first

lap, autonomy, parent

For preschoolers, allow play with ____, use ____, and praise cooperation

equipment, games

For school-age children, consider their desire for ____, sense of ____, demonstrate equipment, and engage curiosity about the body

approval, modesty

For adolescents, be aware they are self-conscious and ____, and need feedback that their body is ____ and ____

introspective, healthy, normal

For older adults, the pace of examination may need to be ____

slower

When vision or hearing is reduced, ____ touch becomes important

physical

The physical appearance assessment of the General Survey includes ____, sex, level of consciousness, skin colour, and facial features

age

The mobility assessment includes ____ and range of motion

gait

The body structure assessment includes stature, ____, symmetry, posture, position, and contour

nutrition

The behaviour assessment includes facial expression, ____ and ____, speech, dress, and personal hygiene

mood, affect

The four vital signs are ____, ____, ____, and ____

temperature, pulse, respirations, blood pressure

Vital sign measurements include weight (kg), height (cm), Body Mass Index (BMI), and ____ ratio

waist-to-hip

The formula for Body Mass Index (BMI) is ____

Weight (kg) / Height (m)²

The formula for Waist-to-Hip Ratio (WHR) is ____

waist circumference / hip circumference

The ____ acts as the body’s thermostat mechanism via feedback

hypothalamus

Temperature is influenced by ____, menstrual cycle, exercise, and age

diurnal cycle

Temperature routes include ____, axillary, rectal, and tympanic membrane

oral

Pulse measures the ____ volume, or the blood pumped by the heart with each beat

stroke

Pulse can be taken at the radial, carotid, brachial, femoral, popliteal, dorsalis pedis, or posterior tibialis ____

artery

When measuring pulse, assess rate (bpm), rhythm, ____ (strong, weak, thready), and elasticity

force

The pulse-to-respiration ratio should be approximately ____

4:1

When assessing respirations, ____ and ____ without telling the patient

look, listen

Four components of blood pressure are ____, ____, pulse pressure, and mean arterial pressure

systolic, diastolic

Blood pressure is influenced by age, gender, ethnocultural background, diurnal rhythm, ____, exercise, emotions, and stress

weight

Physiological factors influencing blood pressure include cardiac output, peripheral resistance, blood volume, ____, and vessel elasticity

viscosity

The ____ blood pressure (top number) is pressure in the artery during left ventricular contraction

systolic

The ____ blood pressure (bottom number) is pressure in the artery between contractions

diastolic

To measure blood pressure, palpate the ____ artery and ensure proper cuff inflation and deflation

brachial

The sounds heard during blood pressure measurement are called ____ sounds

Korotkoff’s

A common blood pressure error is incorrect cuff ____

size

A cuff that is too small produces a falsely ____ reading

high

A drop in blood pressure when standing is called ____ hypotension

orthostatic (postural)

Normal oxygen saturation (SpO₂) is ____

97%–98%

Pulse oximetry works by comparing light emitted to light absorbed by ____ and converting it to %SpO₂

hemoglobin

In infants and children, assess vital signs (TPR) in ____ order

reverse

In older adults, there is a decrease in body ____ and ____

weight, height

Older adults are less likely to be febrile but more at risk for ____

hypothermia

In older adults, pulse may be ____ and respirations ____

irregular, shallower

Older adults typically have increased ____

blood pressure