1002 Part 1 of exam Flashcards
What is subjective data?
= family or patients account of what is going on (patients story)
- data collection - interview and health history
- What is going on here?
What is Objective data?
= physical examination, results of diagnostic test.
- very clear and obvious data
what does this mean?
- collecting estimating and judging the value and significance of the data.
What is a primary assessment?
- crucial first element in every patient encounter
- sets a baseline
- structured and systematic
- A-G approach
- vital signs
- allows for identification of threats to immediate health
- subjective and objective data
- A-G
- identify threats to patients safety first
What is a secondary assessment?
= more focused in depth assessment
- systematic, logical and organised
- body system
- if something in the primary assessment was not right there will be a focused assessment on it
A-G assessment list
Airway Breathing Circulation Disability Exposure Fluid Glucose
Airway
Look
- For signs of airway obstruction
- For evidence of mouth/ neck/ swelling/ haematoma
- For security of artificial airway
Listen
- For noisy breathing e.g. gurgling, snoring or stridor
Feel
- For the presence of air movement
- For security of artificial airway
Breathing
Look
- At chest wall movement, to see it its normal and symmetrical
- To see if the patient is using their neck and shoulder muscles to breath (accessor muscles)
- At the patient to measure their respiratory rate
Listen
- To the patient talking to see if they can complete full sentences
- For noisy breathing e.g. stridor, wheezing
Feel
- For the position of the trachea to see if it is central
- For surgical emphysema or crepitus
- If the patient is diaphoretic (sweaty)
Circulation
Look
- At the skin colour for pallor and peripheral cyanosis
- At the capillary refill time
- At the patient’s central venous pressure and jugular venous pressure
Listen
- To the patient for complaints of dizziness and headaches
- For patients’ blood pressure and heart sounds
Feel
- Your patients hands and feet to see if they are warm or old
- Your patients’ peripheral pulses for presence, rate, quality
Disability
Look
- Level of consciousness
- Facial symmetry, abnormal movements, seizure activity or absent limb movements
- Pupil size, equality and reaction to light
Listen
- To patient’s response to external stimuli and pain
- For slurred speech
- For patient’s orientation to person, place and time
Feel
- For patients response to external stimuli
- For muscle power and strength
Exposure
Look
- For any bleeding e.g. investigate wounds and drains that may be hidden under bed clothes
Listen
- For air leaks in drains
- For bowel sounds
Feel
-The patients abdomen
Fluid
Look
- At the observation and fluid charts, noting the fluid input and output
- At losses from all drains and tubes
- At the amount and colour of the patient’s urine and urinalysis results
Listen
-For patients’ complaints of thirst
Feel
- The skin turgor
Glucose
Look
- At blood glucose level
- For signs of low glucose, including confusion and decreased conscious state
- At medication chart for insulin and oral hypoglycaemics
Listen
- For patients’ complaints of thirst
- For patient’s orientation to person, place and time
Feel
- If the patient is diaphoretic (sweaty, cold or clammy)
What is involved in pain assessment
PQRST
Provocation/ palliation
- what were you doing when it started?
- what caused it?
- what relieves it?
- what aggravates?
Quality/quantity
- what does it feel like - describe words
Region/ radiation
- where is the pain located?
- does it move? where to?
Severity scacle
- scale of 0-10
Timing
- when did the pain start?
- How long did it last?
- how often does it occur
What are the 6 vital signs and their normals?
Blood pressure = 120/80
Heart rate = 60 - 100
Oxygen saturation = 95 - 100%
Respiratory rate = 16-100 bpm
Temperature = 36.2 - 37.5
Pain = 0-10
How do you interoperate heart rate?
• Sites used
• Character of pulse
- Rate, rhythm, strength, equality
• Be aware of factors influencing heart rate
E.g. drugs, emotions, exercise,
haemorrhage, postural changes,
pulmonary conditions
• If HR abnormal or irregular use apical
pulse rate to confirm
Reliability
= Does it measure something correctly?
- can it be relied on every time
- does it represent the consistency of measure obtained
Validity
= does it measure what is is supposed to
- how do i know that the test, scale, instrument i use measure what it is supposed to
- extend to which an instrument reflects the true measurement being observed
How do you avoid Error in measurement?
- repeat
- Check equipment
- Use different piece of equipment
- Calibration - process of comparing the pressure gauge against a known accurate reference manomometer
Ways to reduce error in readings?
- is it on properly
ECG
- no belt buckles
- sit still
- explain that it wont hurt
- put the dots on properly
Blood pressure
- is it on correctly
- remove thick clothing
- is their arm straight?
What is the cardiac cycle?
= one cycle consists of contraction and relaxation of both atrias followed by systole and diastole of both ventricles.
- Initiated by impulse (action potential) from sinus atrial (SA) node
- Period of
- Depolarisation = Contraction - systole
- Repolarisation = Relaxation - diastole
Why does heart rate vary?
- autonomic nervous system regulates the sinus node
- analysis of the sinus rhythm provides information about the state of the autonomic nervous system (sympathetic/ parasympathetic)
How does the blood flow through the heart?
- Superior vena cava + Inferior Vena Cava
- Right Atrium
- Right ventricle
- Pulmonary artery to lung
- lung to Pulmonary vein
- Left atrium
- Left ventricle
Valves open and close together
What is the cardiac conduction?
- pace maker SA node
- generates 60-100 beats/min
- Controlled by sympathetic and parasympathetic
- AV node
- delays impulse 0.07 secs
- Bundle of HIS (AV bundle)
- can initiate and sustain impulse 40-60 min
- Left and right branch bundles
- bundle branches terminate in purkinje fibres
What is in a cardiovascular assessment?
- a-g assessment
Inspection
- skin colour
Palpation
- pulses for circulation - extremities
- capillary refill
- skin temperature
- calves for tenderness
Auscultation
- listen to the heart -> apex beat
ECG
