Assessment Final Flashcards
Your patient states that he has an allergy to PCN, what should be your next question?
What is your reaction? How sever is it?
Describe how the Chief Complaint is recorded, and given an example.
Subjective statement client gives about why seeking healthcare. “My Head Hurts!”
When doing the general survey what are you assessing?
Appearance, breathing pattern, posture, cleanliness, skin pink or warm
What information is needed when collecting a medication history?
Dose, reason, time taking it, last time took it, route, and history, name
Therapeutic communication –
- active listening – listening then repeating it back
- restatement – help pt to expand on what they are saying or use different words
- reflection – summarizing main parts
- encouraging elaboration – trying to get pt to talk more
- silence – gives pt time to pick the words they want to use
- focusing – narrow down concerns we have about health history
- clarification – ask pt what do they mean
- summarizing
- open ended questions
- eye contact
Nontherapeutic communication –
- false reassurance – can’t guarantee anything, every pt is different
- sympathy – takes focus off of pt and put on self
- unwanted advice – “my mother had this done and did this”
- biased questions – “do you use drugs”
- changing the subject – don’t run away from info we feel uncomfortable
- distractions – ex trying to chart while in pts room
- technical or overwhelming language – supposed to teach at a 4th grade level
- interrupting - give pt time to explain
- arms crossed
Open-ended questions; when collecting information about weight what would be an appropriate open-ended question to ask your patient?
Have you had any changes in your weight?
Describe the difference between subjective and objective data. What are some examples?
Subjective: pain
Objective: anything measurable
What are the steps for completing a symptom analysis
OLD CARTS (onset, location, duration, character, associated or aggravating factors, relieving factors, timing, severity)
how would you assess severity?
use pain scale
- How would you document your findings for a general survey? For example, you have a patient that appears depressed and does not make direct eye contact during the history Assessment.
Document what you see
What are the normal age related changes for our older adult patients?
Decrease perception, decreased mobility (everything goes down except adipose tissue)
Name the stage of development according to Erikson.
Integrity vs. Despair. (sense of satisfaction of a life well lived)
What is the best position to take a history in the older adult with hearing loss?
If elderly sit in front of pt, slow speech down, make sure they can see your mouth
What are some psychosocial factors/ concerns in the older adult?
Life roles and attitudes
What is the technique for taking a rectal temperature?
1 ½ adult, 1 child, ½ infant (Approximately 1 degree higher than normal)
What range is considered pre-hypertension? **
Pre-hypertension – 120-139 / 80-89
Stage l hypertension – 140-159 / 90-99
Stage 2 hyperstion - >160 / >100
Grading of peripheral pulses, what is considered normal and abnormal?
2+ normal
0 absent, 1 diminished, 3 full, 4 strong
What is pulse pressure?
The difference between the SBP and the DBP and reflects the stroke volume (normal is 40 mm Hg
- How long should you palpate the radial pulse when assessing rate, how long for the apical pulse
Radial – 30 seconds x 2
Apical – 1 minute
When assessing blood pressure what does systolic pressure represent, and what does diastolic pressure indicate?
Systolic – contraction of the left ventricle at the beginning of systole
Diastolic – left ventricle relaxes between beats
What are some risk factors for atelectasis?
collapsed section of alveoli from immobility, obstruction, compression, or decreased surfacant) risk factor – immobility
Bradypnea -
<12 breaths per minute
Tachypnea –
abnormally rapid >20
Apnea –
respirations cease for several seconds
Hyperventilation –
rate and depth increase (hypocardia can occur) (paniac attack)
Hypoventilation –
rate and depth decrease, depth of ventilation = depressed (hypercardia)
Biots –
rapid pause rapid pause (brain stem injuries)
Kussmauls –
deep when blood sugar is hig
Cheyne-strokes -
normal in children and elderly, regular irregular rhythm that cycles from deep and fast to shallow and slow
When assessing a patient of darker skin color you note a gray dullness, what does this indicate?
Cyanosis
Vesicular sounds
soft airy breeze, inspiration greater then expiration, heard over most of the lung fields
Bronchovesicular sounds
– inspiration = expiration, between 2nd intercostal spaces, between scapula
Brochial sounds
harsch, coarse sound, over trachea, inspiration less than expiration
During percussion what should you hear over most lung fields and what could cause dullness. If you not dullness at T10 this usually indicates what?
The diaphragm
How do you assess for fremutis?
99 test
Rhochi –
(low pitch) sonorous
Wheezing –
musical, sibilant (high pitch)
Crackles –
popping
Friction rub –
high pitch grating
What are the physical symptoms of dyspnea?
SOB, increase rate, use of abdominal muscles, tripod position (definition: labored breathing and breathlessness)
