NURS 2092 Health Assessment Exam 2 Study Guide.
Technical Equipment and Uses:
Stethoscope
1. Parts of the Stethoscope
a. Bell - for low pitch sounds
b. Diaphragm - is used for high pitch sounds
2. What is Bronchophony?
a. Ask the PT to say 99 while you listen with a stethoscope. If abnormal it will sound more distinct throu
the stethoscope then normal.
3. What is egophony?
a. Ask PT to pronounce 'ee-ee-ee--ee" sound. If the noise changes, it is abnormal.
Health Assessment:
Skills; inspection, palpation, percussion, auscultation
1. Assessing Abdominal Tenderness
a. 1st inspect, 2nd auscultate, 3rd percuss, 4th palpate
b. What step do you do first in physical exam of the abdominal?
i. Auscultate before percussing or palpating the abdominal
2. Skills in order
a. Inspection, Palpation, Percussion, Auscultation
i. Palpation uses the sense of touch to assess the patient for these factors.
ii. Inspection involves vision
iii. Percussion assesses through the use of palpable vibrations and audible sounds
iv. Auscultation uses the sense of hearing
b. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swellin
when the nurse is as sessing a patient?
i. Palpation
c. Where do you palpate the
pulses? temporal
external Carotids
Brachi
al
Radial
Ulnar
Aortic
Femor
al
Poplit
, eal
Dorsalis pedis
Posterior tibial
d. How many steps and names to the steps of Auscultating HEART SOUNDS?
i. Acronym is APETM
1. Aortic - 2nd intercostal space, right of sternal border
2. Pulmonic - 2nd intercostal space left sternal border
3. Erb's point- 3rd intercostal space at the left sternal border
4. Tricuspid- 4th or 5th intercostal space at the left lower sternal border.
5. Mitral- 5th intercostal space near the left midclavicular line, apex of the heart
Other Assessments: hearing, skin, vision, balance
1. Hearing/Ear
a. Which way to you pull the ear for adult Vs. child?
Pull the pinna up and back on adult or older child. Pull pinna down for child younger than 3.
b. What do you try to locate on the tympanic membrane?
Cone of light
c. What is the gross hearing test?
Whisper test
2. Visual/ Eyes
a. How to test for Visual acuity
i. Use the Snellen eye chart. Stand 20 feet away from the chart. Test one eye at a time
anything less than 20/40 should be referred for correction
3. Sk
i Techniques of examination of the skin:
n
a
.
i. Note
characteristics of:
Color
Edema
Moisture
Temperatur
e Texture
Mobility and turgor
Lesions
ii. ABCDE of skin assessment
A- asymmetry
B- Border irregularity
C- color
D- diameter
E- evolution or elevation
Technical Equipment and Uses:
Stethoscope
1. Parts of the Stethoscope
a. Bell - for low pitch sounds
b. Diaphragm - is used for high pitch sounds
2. What is Bronchophony?
a. Ask the PT to say 99 while you listen with a stethoscope. If abnormal it will sound more distinct throu
the stethoscope then normal.
3. What is egophony?
a. Ask PT to pronounce 'ee-ee-ee--ee" sound. If the noise changes, it is abnormal.
Health Assessment:
Skills; inspection, palpation, percussion, auscultation
1. Assessing Abdominal Tenderness
a. 1st inspect, 2nd auscultate, 3rd percuss, 4th palpate
b. What step do you do first in physical exam of the abdominal?
i. Auscultate before percussing or palpating the abdominal
2. Skills in order
a. Inspection, Palpation, Percussion, Auscultation
i. Palpation uses the sense of touch to assess the patient for these factors.
ii. Inspection involves vision
iii. Percussion assesses through the use of palpable vibrations and audible sounds
iv. Auscultation uses the sense of hearing
b. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swellin
when the nurse is as sessing a patient?
i. Palpation
c. Where do you palpate the
pulses? temporal
external Carotids
Brachi
al
Radial
Ulnar
Aortic
Femor
al
Poplit
, eal
Dorsalis pedis
Posterior tibial
d. How many steps and names to the steps of Auscultating HEART SOUNDS?
i. Acronym is APETM
1. Aortic - 2nd intercostal space, right of sternal border
2. Pulmonic - 2nd intercostal space left sternal border
3. Erb's point- 3rd intercostal space at the left sternal border
4. Tricuspid- 4th or 5th intercostal space at the left lower sternal border.
5. Mitral- 5th intercostal space near the left midclavicular line, apex of the heart
Other Assessments: hearing, skin, vision, balance
1. Hearing/Ear
a. Which way to you pull the ear for adult Vs. child?
Pull the pinna up and back on adult or older child. Pull pinna down for child younger than 3.
b. What do you try to locate on the tympanic membrane?
Cone of light
c. What is the gross hearing test?
Whisper test
2. Visual/ Eyes
a. How to test for Visual acuity
i. Use the Snellen eye chart. Stand 20 feet away from the chart. Test one eye at a time
anything less than 20/40 should be referred for correction
3. Sk
i Techniques of examination of the skin:
n
a
.
i. Note
characteristics of:
Color
Edema
Moisture
Temperatur
e Texture
Mobility and turgor
Lesions
ii. ABCDE of skin assessment
A- asymmetry
B- Border irregularity
C- color
D- diameter
E- evolution or elevation
