Assessment Flashcards
What should you check prior to seeing a patient?
- Medical records (case notes)
- Observation (charts)
- Investigations eg. Imaging & Targeted evaluation of tests (blood sample or gas, sputum, other microbiology)
- Talk to Patient care nurse &/or treating doctor if needing to clarify any contra- indications/precautions
What information should we gather from social history?
Accomodation Home support Work Pre-admission activity & mobility ADLs Home set up Falls Hx
What information can we get from nursing observation charts?
Temperature O2 sats Blood pressure Pulse rate RR Blood glucose
What investigations may we see?
Medical imaging (X-ray/CT) ECG Spirometry ABG Blood exam (FBE) Coagulation studies Microculture and sensitivity tests
What are the important initial parts to cover in a subjective exam?
Hand hygiene
Observations (positioning, comfort, RR, colour, wakefullness, O2 worn correctly)
Introduce self
Draw curtains/maintain privacy
Explain my role/purpose
Gain consent
Assess assessments and general environment
What are the cardinal signs?
Pain (including chest) Cough Sputum Haemoptysis Breathlessness Wheeze
What are some important special questions to ask in an acute subjective?
Smoking Hx Mobility Social Hx Physical activity & exercise tolerarnce Self-managment Goals Medications
What do we want to know about pain?
Type of pain relief and when they last had it Current pain? Where? Score out of 10? At rest ? With movement? When coughing? Pain elsewhere?
What are some possible causes of chest pain?
Pleural
Musculoskeletal
Cardiac
Mediastinum
Pleural causes of pain?
Pleurisy
Pulmonary embolus
Pneumothorax
Tumours
Musculoskeletal causes of pain?
Rib #
Muscular
Costochondritis
Neuralgia
Cardiac causes of pain?
IHD: angina
IHD: myocardial infarction
Pericarditis
What is angina?
Chest pain caused by reduced blood flow to the heart.
What is pericarditis?
Swelling & irritation of the pericardium (membrane surrounding the heart)
Mediastinum causes of pain?
Dissecting aortic aneurysm
Oesophageal mediastinal shift
What is a dissecting aortic aneurysm?
A tear in the inner layer of the aorta
What is a oesophageal mediastinal shift?
Deviation of the pleural structures towards one side of the chest cavity. Usually due to asymmetry in intrathoracic pressures eg. pleural effusion
What are some symptoms commonly associated with chest pain or SOB?
- fainting/syncope
- weakness
- light-headedness (hypotension)
- loss of consciousness
- Palpitations (arrhythmia)
What may pink sputum indicate?
Pulmonary oedema
What may dark green/brown sputum indicate?
Pseudomonas
What may yellow sputum indicate?
Haemophilus (bacterial infection caused by Haemophilus influenzae type b.
Chronic causes of breathlessness?
- COPD
- lung cancer
- ILD
- anaemia
Sudden causes of breathlessness?
- acute asthma
- PE
- pneumothorax
- cardiac: MI/pulm oedema/arrhythmia
- anaphylaxis
- anxiety
Recent causes of breathlessness?
- exacerbation COPD
- Pneumonia
- LHF
- Pleural effusion
- other: metabolic acidosis, anaemia
What questions should we ask regarding smoking?
- Have you ever smoked?
- How long for?
- How many cigarettes a day?
- When did you stop?
What is the calculation for someones pack year smoking Hx?
pkts/day x years smoked
What general observations can be made in the objective exam?
- Level of consciousness
- Colour, face, skin
- Posture
- Attachments
- Surgical incision
- Hands & feet (clubbing? discolouration?)
Common acute care attachments?
– Oxygen delivery and oximeter – Arterial line – Intra-venous (CVC, PICC, Jelco, PCA) – Chest drains (ICC, UWSD) – Nasogastric tube (NGT) – Wound drains – Epidural – Stoma – Urinary catheter – ECG /pacing wires
What visual assessments can we make from looking at a patient breathing?
- Inspiratory:Expiratory = 1:2 = normal
- Rate
- Accessory muscle use
- Active expiration
- Nasal flaring
- Pursed lip breathing
What should we listen for during the objective exam?
- Auscultation
- Cough
4 ways to describe a cough:
strong/weak
dry/moist
effective/ineffective
productive/non-productive
What should we feel for in the objective exam?
- Basal expansion (bucket handle action & symmetry)
- Diaphragm movement (upper chest vs abdominal breathing)
