Baseline assessment Flashcards
What does Comprehensive assessment include?
- Physical assessment (more objective)
- Health History Assessment (more subjective)
What part of the assessment can a UAP (unlicensed assistive personnel) do?
- vital signs
- pain report
- blood glucose
- HT and WT
What are the types of assessments?
- Comprehensive physical assessment
- Focused physical assessment
- System-specific assessment
- Ongoing assessment
Who does the comprehensive physical assessment?
Usually the RN
Who is resposible for doing the Ongoing assessment?
LPN and RN
How do you prepare for a physical examination?
1) prepare yourself (knowledge)
2) Prepare the environment
3) Prepare the pt.
What things do you need to do to prepare the environment?
1) Privacy
2) Sound and lighting
3) Supplies
- TIming
- Rapport
What kind of modifications do you need to do for an infant?
Have the parent hold the baby
What modifications do you need for Toddlers
- Give choices
- Praise
- Include parents
What modifications do you need for school age?
- Develop rapport
- Demonstrate equipment
What modifications do you need for Adolescents?
- Privacy
- Behavior influenced by peers
Define Standing.
Upright posture w/ both feet flat on the floor
Define sitting
Upright at side of be or exam table
What position would you have someone in if you are wanting to examin their stomach?
Supine
What position do you have the pt in to exam the pt’s head and neck, chest cardiovascular system, breasts and assess vital signs.
Sitting
Define Auscultation.
Listening
Define percussion
touch
What does I.P.P.A.Q. mean
Inspect
Palpate
Percuss
Auscultate
Question
What is a normal pulse range
60-100 beats/min
What is the normal range for Respirations?
12-20 breahs/min
What is the normal range for BP Systolic
100-119
What is the normal range for Diastolic BP
60-80
Define papation.
- Use of touch
- Used to evaluate
- Examine areas of discomfort last
How do you assess skin temp during palation?
Use the dorsal part of hand
What are you evaluating for during palpation?
- Temp
- Skin texture
- Moisture
- Anatomical landmarks
- Abnormalities
What do you exam last during palpation
The area of pain
Who does the percussion exam?
Usually done by advanced practice health care providers.
Define Auscultation
- Use of hearing to collect data
Define direct auscultation.
Listening without a tool
Define Indirect auscultation
Listening w/ a stethoscope
What do you listen to on the Diaphragm on the stethoscope?
- High pitched sounds
- Heart, lungs, bowel
What do you listen to on the Bell of a stethoscope.
- Low pitched sounds
- Murmurs and bruits
When do you use olfaction to gather data.
- Alcohol
- Urine
- Fruity breath
- Clostridium difficile
- Infection
Describe a Comprehensive Physical assessment.
- Head to toe
- Body systems approach
- Includes the physical assessment and health hx.
Describe a Focused physical assessment.
-Focus on the problem
- Narrow approach
Define a system-specific assessment.
- Focused
- Specific body system
Define an ongoing assessment.
- As needed
- Mini assessments every time you encounter the pt.
What is the purpose of the Initial assessment?
- Are related to the pt’s reason for seeking nursing or medical assistance
- Provides guidance for care
- Help determine need for further assessment
When does a nurse perform an initial assessment
Completed when the pt first comes to healthcare agency.
When is an Ongoing assessment performed?
-Performed as needed, at any time after the initial database is completed.
What are the data points on an Ongoing assessment?
- Help identify new problems
- Follow up on previously identified problems.
What do data points reflect w/ examples.
The ever-changing state of the client
- Vital signs may change rapidly, which is an important indicator of developing or resolving health problems.
What modifications does a nurse make for a preschooler?
- Allow child to help
- Reassure
- Compliment
What modifications does a nurse make for Elderly people?
- Limit position changes
- Assess pt. support systems
Define the supine position
- It includes Fowler’s and semi-Fowler’s
- Lying flat on the back w/ arms and legs fully extended.
Define the Dorsal Recumbent position
Supine with knees flexed
Define the Sim’s position.
Flexion of the hip and knees in a side-lying position
Define the Prone positiion
Lying on stomach.
When can a Prone position be used?
Can be used to examine the musculoskeletal system and the back and buttocks.
When would you use the Dorsal recumbent position.
- Used to assess the abdomen if the pt is experiencing abdominal or pelvic pain.
- Position for Foley insertion.
When would you use the Sim’s postion?
Used to examine the rectal area and for insertion of an enema
-Do not use if the pt has a total hip replacement.
When would you use the Supine position?
Used to assess the abdomen, breasts, extremities, and pulses.
- If pt experiences SOB, raise the HOB
What happens during the physical assessment?
Using our senses/techniques to gather objective data about the body
When does the inspection general survey start/ what do you use?
- Use of sight
- Observation and visual examination
- Starts as soon as you encounter the pt.
- Equipment: Otoscope, penlight, ophthalmoscope.
What are the general characteristics you would observe during an inspection?
- Vital signs
- Age, gender, race
- Body type and posture
- Gait
- Speech patterns
- Mental state and affect
- Grooming/hygiene
What is the normal rage for Oral/tympanic temp?
98-98.6
36.7 - 37
What is the normal range for Rectal/temporal temp?
99-99.6
37.2 - 37.6
