Nursing Assessment Techniques Quiz

Pain Assessment

• Pain assessment involves questions to determine pain onset.
• Questions should target where the pain began, what the person was doing at the time, and whether the pain began suddenly or gradually.
• Acute pain has a sudden onset and short duration.
• Ischemic pain gradually increases in intensity.
• Persistent pain (chronic pain) lasts longer than one month.

Culture and Pain

• Patients from diverse cultures may use different words to describe pain, potentially unfamiliar to the nurse.

Health Preventions

• Primary prevention involves vaccines and health education.
• Secondary prevention focuses on screenings and exams.
• Tertiary prevention centers on managing diseases.

Subjective Data

• Subjective data, collected directly from the patient, includes health history and symptoms.
• Symptoms are considered subjective.

Objective Data

• Objective data, collected during a physical exam, includes vital signs and techniques like inspection, palpation, percussion, and auscultation.
• Signs are considered objective.

Techniques of Physical Assessment

• Physical assessments use techniques like inspection (visual examination of the body, including movement and posture, and smell).
• Other techniques include palpation (feeling texture, size, shape, consistency, pulsation, and location of body parts), and palpation for tenderness or pain.
• Palpation should be gentle, with warm hands and short nails to prevent discomfort.

Percussion

• Percussion is a technique used to determine the size, borders, and consistency of internal organs.
• It helps detect tenderness and identify the extent of fluids in body cavities.
• Direct percussion involves striking a finger or hand directly against the patient's body.
• Indirect percussion uses both hands, with different methods based on the body area being assessed.

Percussion Tones

• Percussion is used to evaluate the intensity, pitch, duration, and quality of sounds produced within the body.
• Different areas of the body produce different sounds (e.g., lungs resonate, bones dull).

Auscultation

• Auscultation involves listening to sounds within the body to assess organs and bodily systems.
• A stethoscope is used to block extraneous sounds and amplify the sounds produced by the heart, blood vessels, lungs and intestines.
• Characteristics include intensity, pitch, duration and quality of sounds.

Positions for Examination

• Sitting position is usually used to assess the head, neck, back, posterior and anterior thorax, lungs, breasts, axilla, heart, abdomen, and upper extremities.
• Supine (lying on back) is a position helpful in assessing the same areas.
• Dorsal recumbent (lying on back with knees bent) may be more comfortable for patients with certain pain conditions.
• Lithotomy (lying on back with legs raised and separated) is beneficial for assessing the female genitalia and the genital tract.
• Sims' position (lying on left side with knees drawn up) is useful for rectal and vaginal examinations.
• Prone (lying face down) is used for musculoskeletal issues.
• Lateral recumbent (lying on side) is appropriate for assessing the heart and respiratory systems.
• Knee-chest position (knees bent towards the chest, lying on abdomen) is useful for rectal examination.

Phases of Interview

• The interview process begins with an introduction phase where the interviewer greets and establishes the purpose of the interview.
• The discussion phase entails facilitating communication and collecting data.
• The summary phase involves summarizing the collected data to reach a common understanding involving the patient.

Types of Interview Questions

• Open-ended questions encourage free-flowing responses, allowing patients to describe their condition in their own words.
• Closed-ended questions collect precise, specific information.

Techniques that Enhance the Interview

• Active listening involves concentrating on spoken words and nonverbal cues to enhance comprehension.

Physical Setting for Interview

• Conduct interviews in private, quiet, and comfortable rooms to minimize distractions.
• Importance of privacy, especially when discussing highly personal issues.
• Consider the amount of personal space needed by the patient.
• Temperature settings and unnecessary noise should be controlled.

Clustering of Data

• Organizing data by body systems or conceptual formats aids in problem identification.

Hearing Impairment

• When interacting with patients with hearing impairments, the interviewer needs to speak slowly and clearly.
• Face the patient, and hold the interview in a quiet room to make it easier to hear.

Hand Washing

• Hand hygiene is essential before and after direct patient contact.
• It involves 15-20 seconds of washing or sanitizing hands.

Rectal Temperature

• Rectal temperature measurement should be avoided in trauma patients, those with rectal surgeries, cancer treatment, and those with gastrointestinal issues (e.g., GI bleeds, post-MI (heart attack) patients).

Vital Signs

• Heart rate (infant, toddler, school-aged, adolescent, adult ranges)
• Respiratory rate (infant, toddler, school-aged, adolescent, adult ranges)
• Blood pressure (infant, toddler, school-aged, adolescent, adult ranges)

What Vital Signs Increase With Temperature?

• High blood pressure is often associated with elevated temperatures.
• High respiratory rates are also common with an increase in temperature.

Ganglion Cysts

• Ganglion cysts are fluid-filled lumps often appearing on joints or tendon sheaths, most frequently in the wrist.
• Ganglion cysts on ankles and feet are also possible.
• Ganglion cysts often resolve on their own and occasionally require treatment, though they do not require immediate concern.

Hypernatremia

• Hypernatremia is a condition characterized by high sodium levels.
• It's crucial to avoid using 0.9% saline solution in patients with elevated sodium levels.

Medical Terminology

• This section covers basic word structure, prefixes, suffixes, and their meanings.
• The terms are essential for understanding medical concepts.

Cardiology and Hematology

• Cardiology is the study of the heart.
• Hematology is the study of blood.
• Gastritis is a condition of the stomach lining.