FAQs
Percussion produces sounds on a spectrum from flat to dull depending on the density of the underlying tissue. Areas of well-aerated lung will be resonant, or tympanic, to percussion. Dullness to percussion indicates denser tissue, such as zones of effusion or consolidation.
When examining the abdomen, which of the following techniques should the nurse perform first? ›
Always follow this sequence: inspection, auscultation, percussion, and palpation. Changing the order of these assessment techniques could alter the frequency of bowel sounds and make your findings less accurate.
Which of the following characteristics is associated with a stage 2 pressure ulcer? ›
Stage 2:Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister.
What is the sequence of actions the client should be taught when using a modified 3 point crutch gait? ›
Identify the sequence of the actions the client should be taught when using a modified 3-point crutch gait. Answer: Bear weight on unaffected leg, transfer weight to crutches, advance unaffected leg, shift weight from crutches to unaffected leg, and go up stairs.
What sound should be elicited when percussing over dense tissue? ›
Dullness is the normal sound heard when percussing tissues that are dense in consistency, such as the liver. Dullness is typically considered an abnormal sound if elicited with percussion over the lungs or the intestines, stomach, or bladder.
What type of sound is elicited when percussing lungs filled with air? ›
The purpose of percussion (Table 46.3) is to determine if the area under the percussed finger is air filled (sounding resonant like a drum), fluid filled (a dull sound) or solid (a flat sound).
How long should you listen to bowel sounds in each quadrant? ›
Presence. Normally, bowel sounds are present in all four quadrants. This means that peristalsis is occurring and contents are moving through the intestines. Only document the absence of bowel sounds after listening in each quadrant for five minutes.
Which skill should the nurse implement first when assessing a patient's abdomen? ›
WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation. Use them in sequence—unless you're performing an abdominal assessment. Palpation and percussion can alter bowel sounds, so you'd inspect, auscultate, percuss, then palpate an abdomen.
What are the 4 assessment techniques used in abdominal examination? ›
Following a quick assessment, the abdominal examination consists of 4 basic components—inspection, palpation, percussion, and auscultation. Inspection of the abdomen: The general examination of the abdomen begins with the patient in a completely supine position.
Which of the following pressure relieving devices should not be used? ›
Pressure relieving equipment
Do not use ring and/or doughnut cushions as these can cause further pressure damage. If you are assessed as being at risk of developing a pressure ulcer, your healthcare professional will advise you on: the appropriate pressure relieving equipment for chairs and/or your bed.
Keep the pressure areas clean and dry. Always look for redness and numbness. Provide air mattress. Use pillows to reduce pressure.
How often should patients be repositioned to prevent pressure ulcers? ›
Document the frequency of repositioning required. Encourage adults who have been assessed as being at high risk of developing a pressure ulcer to change their position frequently and at least every 4 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed.
What is the 4 point gait? ›
Four-Point Gait
This is most commonly used to provide assistance with walking when both legs are in a weakened condition. To use this gait, put the right crutch out and step with the left foot. Then put the left crutch out and step with your right foot. The pattern is right crutch- left foot and left crutch-right foot.
What should be the first step when using behavior modification? ›
All six steps are important:
- Choose a problem behavior to change.
- Measure the problem behavior by collecting data.
- Determine the function (purpose) of the problem behavior.
- Conduct a functional behavior assessment.
- Create a behavior intervention plan.
- Teach a new alternative behavior.
Two-point gait: The left crutch and right leg move forward followed by the right crutch and left leg. Three-point gait: This is the most used technique. The left and right crutch along with the injured leg are both advanced while the uninjured leg supports the body weight.
What are the sounds elicited by percussion? ›
There are three main medical percussion sounds: resonance (heard over lungs), tympany (heard over the air-filled bowel loops), and dullness (heard over fluid or solid organs).
What is the percussion note for consolidation of the lungs? ›
Dull percussion note (the sound heard over solid tissues): over the liver in the right lower anterior chest and over the heart in the left anterior chest. When percussion of the lungs elicits this sound, it is indicative of consolidation.
What do you hear on percussion in pneumothorax? ›
The percussion sound on the affected side has an exaggerated, resonant and booming quality. The percussion note is exaggerated partly because a stethoscope is used and partly because, in the supine patient, air localizes upwards to the anterior thorax.
Which sound expected to hear while performing percussion over the healthy lungs area? ›
Since lungs are mostly filled with air that we breathe in, percussion performed over most of the lung area produces a resonant sound, which is a low pitched, hollow sound.
