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1030 Fundamental > Baseline assessment > Flashcards

Baseline assessment Flashcards

1
Q

What does Comprehensive assessment include?

A
  • Physical assessment (more objective)
  • Health History Assessment (more subjective)
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2
Q

What part of the assessment can a UAP (unlicensed assistive personnel) do?

A
  • vital signs
  • pain report
  • blood glucose
  • HT and WT
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3
Q

What are the types of assessments?

A
  • Comprehensive physical assessment
  • Focused physical assessment
  • System-specific assessment
  • Ongoing assessment
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4
Q

Who does the comprehensive physical assessment?

A

Usually the RN

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5
Q

Who is resposible for doing the Ongoing assessment?

A

LPN and RN

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6
Q

How do you prepare for a physical examination?

A

1) prepare yourself (knowledge)
2) Prepare the environment
3) Prepare the pt.

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7
Q

What things do you need to do to prepare the environment?

A

1) Privacy
2) Sound and lighting
3) Supplies

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8
Q
A
  • TIming
  • Rapport
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9
Q

What kind of modifications do you need to do for an infant?

A

Have the parent hold the baby

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10
Q

What modifications do you need for Toddlers

A
  • Give choices
  • Praise
  • Include parents
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11
Q

What modifications do you need for school age?

A
  • Develop rapport
  • Demonstrate equipment
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12
Q

What modifications do you need for Adolescents?

A
  • Privacy
  • Behavior influenced by peers
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13
Q

Define Standing.

A

Upright posture w/ both feet flat on the floor

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14
Q

Define sitting

A

Upright at side of be or exam table

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15
Q

What position would you have someone in if you are wanting to examin their stomach?

A

Supine

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16
Q

What position do you have the pt in to exam the pt’s head and neck, chest cardiovascular system, breasts and assess vital signs.

A

Sitting

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17
Q

Define Auscultation.

A

Listening

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18
Q

Define percussion

A

touch

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19
Q

What does I.P.P.A.Q. mean

A

Inspect
Palpate
Percuss
Auscultate
Question

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20
Q

What is a normal pulse range

A

60-100 beats/min

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21
Q

What is the normal range for Respirations?

A

12-20 breahs/min

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22
Q

What is the normal range for BP Systolic

A

100-119

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23
Q

What is the normal range for Diastolic BP

A

60-80

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24
Q

Define papation.

A
  • Use of touch
  • Used to evaluate
  • Examine areas of discomfort last
25
Q

How do you assess skin temp during palation?

A

Use the dorsal part of hand

26
Q

What are you evaluating for during palpation?

A
  • Temp
  • Skin texture
  • Moisture
  • Anatomical landmarks
  • Abnormalities
27
Q

What do you exam last during palpation

A

The area of pain

28
Q

Who does the percussion exam?

A

Usually done by advanced practice health care providers.

29
Q

Define Auscultation

A
  • Use of hearing to collect data
30
Q

Define direct auscultation.

A

Listening without a tool

31
Q

Define Indirect auscultation

A

Listening w/ a stethoscope

32
Q

What do you listen to on the Diaphragm on the stethoscope?

A
  • High pitched sounds
  • Heart, lungs, bowel
33
Q

What do you listen to on the Bell of a stethoscope.

A
  • Low pitched sounds
  • Murmurs and bruits
34
Q

When do you use olfaction to gather data.

A
  • Alcohol
  • Urine
  • Fruity breath
  • Clostridium difficile
  • Infection
35
Q

Describe a Comprehensive Physical assessment.

A
  • Head to toe
  • Body systems approach
    • Includes the physical assessment and health hx.
36
Q

Describe a Focused physical assessment.

A

-Focus on the problem
- Narrow approach

37
Q

Define a system-specific assessment.

A
  • Focused
    • Specific body system
38
Q

Define an ongoing assessment.

A
  • As needed
    • Mini assessments every time you encounter the pt.
39
Q

What is the purpose of the Initial assessment?

A
  • Are related to the pt’s reason for seeking nursing or medical assistance
  • Provides guidance for care
  • Help determine need for further assessment
40
Q

When does a nurse perform an initial assessment

A

Completed when the pt first comes to healthcare agency.

41
Q

When is an Ongoing assessment performed?

A

-Performed as needed, at any time after the initial database is completed.

42
Q

What are the data points on an Ongoing assessment?

A
  • Help identify new problems
  • Follow up on previously identified problems.
43
Q

What do data points reflect w/ examples.

A

The ever-changing state of the client
- Vital signs may change rapidly, which is an important indicator of developing or resolving health problems.

44
Q

What modifications does a nurse make for a preschooler?

A
  • Allow child to help
  • Reassure
  • Compliment
45
Q

What modifications does a nurse make for Elderly people?

A
  • Limit position changes
  • Assess pt. support systems
46
Q

Define the supine position

A
  • It includes Fowler’s and semi-Fowler’s
  • Lying flat on the back w/ arms and legs fully extended.
47
Q

Define the Dorsal Recumbent position

A

Supine with knees flexed

48
Q

Define the Sim’s position.

A

Flexion of the hip and knees in a side-lying position

49
Q

Define the Prone positiion

A

Lying on stomach.

50
Q

When can a Prone position be used?

A

Can be used to examine the musculoskeletal system and the back and buttocks.

51
Q

When would you use the Dorsal recumbent position.

A
  • Used to assess the abdomen if the pt is experiencing abdominal or pelvic pain.
  • Position for Foley insertion.
52
Q

When would you use the Sim’s postion?

A

Used to examine the rectal area and for insertion of an enema
-Do not use if the pt has a total hip replacement.

53
Q

When would you use the Supine position?

A

Used to assess the abdomen, breasts, extremities, and pulses.
- If pt experiences SOB, raise the HOB

54
Q

What happens during the physical assessment?

A

Using our senses/techniques to gather objective data about the body

55
Q

When does the inspection general survey start/ what do you use?

A
  • Use of sight
  • Observation and visual examination
  • Starts as soon as you encounter the pt.
  • Equipment: Otoscope, penlight, ophthalmoscope.
56
Q

What are the general characteristics you would observe during an inspection?

A
  • Vital signs
  • Age, gender, race
  • Body type and posture
  • Gait
  • Speech patterns
  • Mental state and affect
  • Grooming/hygiene
57
Q

What is the normal rage for Oral/tympanic temp?

A

98-98.6
36.7 - 37

58
Q

What is the normal range for Rectal/temporal temp?

A

99-99.6
37.2 - 37.6

59
Q
A

1030 Fundamental (4 decks)

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