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1030 Fundamental > Baseline Assessment Procedure > Flashcards

Baseline Assessment Procedure Flashcards

1
Q

Before beginning the assessment what does the nurse need to do?

A

WIIPPE:
W - wash your hands + wear gloves
I - Introduce self
I - Identify pt
P - Provide privacy
P - Position pt.
E - Explain procedure

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2
Q

What two pt identifiers do nurses us and what do you check them against?

A

1) Pt name
2) pt D.O.B

Have pt tell you and check it against their wrist band.

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3
Q

What do you need to assess w/ the neurological system?

A
  • Mental status
    • Level of consciousness and orientation (LOC)
      or
    • Glasgow
  • Pupillary responses PERRLA
  • Deficits
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4
Q

How do you test a level of consciousness (LOC)

A

A&O x 4 = Alert and oriented to
- Person
- Place
- Time
- Situation

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5
Q

Do you document both a LOC and a GCS?

A

No, do one or the other

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6
Q

What do you score for on a Glasgow Coma Scale?

A
  • Eye opening response
  • Best verbal response
  • Best motor response
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7
Q

Describe the PERRRLA

A

Pupils are equal, round, reactive to light and accommodation.
- Direct and Consensual
- They should accommodate equally

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8
Q

What does it mean to have your pupils accommodate equally?

A
  • pupils should constrict and eyes cross as a person attempts to focus on an item moving toward them.
  • Distant = dilated
  • Close = Constricted
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9
Q

What is the lowest you can get on a Glasgow Coma Scale (GCS)

A

3

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10
Q

What is the highest you can get on a Glasgow Coma Scale (GCS)

A

15

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11
Q

What neurological system deficits do you check for?

A
  • Facial drooping
  • Drooling
  • Slurred speech
  • Confusion
  • Balance issues
  • Muscle weakness
  • Partial or complete paralysis
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12
Q

When a pt has head trauma what needs to be done.

A

A focused assessment.

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13
Q

What is a focused assessment?

A
  • Assess LOC
  • Vital signs
  • PERRLA
  • Assess strength of hand grip and movement of extremities.
  • Determine sensation to touch/pain in extremities
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14
Q

What do you check for the cardiovascular system

A
  • Listen to rate/rhythm
  • 5 names/landmarks and location each heart site (A.P.E.T.M)
  • Check pulses, capillary refill, temp, edema, color in all 4 extremities
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15
Q

What are the 5 areas for listening to the heart?

A

1) Aortic
2) Pulmonic
3) ERB’s Point
4) Tricuspid
5) Mitral

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16
Q

Where is the aortic valve?

A

Right 2nd intercostal space

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17
Q

Where is the pulmonic space?

A

Left 2nd intercostal space

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18
Q

Where is the ERB’s point?

A

(s,s) Left 3rd intercostal space

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19
Q

Where is the best place to listen to the Apical pulse

A

the Mitral valve

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20
Q

Where is the Tricuspid

A

Lower left sternal border 4th intercostal

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21
Q

Where do you listen to the Mitral?

A

Left 5th intercostal, medial to Midclavicular line

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22
Q

S1 and S2 are heard equally at what spot?

A

ERBs point

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23
Q

What circulation are you looking at w/ the cardiovascular system?

A

Peripheral circulation

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24
Q

Capillary refill should be less than what?

A

3 seconds

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25
Q

With skin color, what is a cause of Pallor

A

Shock or blood loss

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26
Q

With skin color, what does Cyanotic mean.

A

blue-gray
Poor oxygenation

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27
Q

W/ Skin color, what does mottling mean?

A

Blotchy marbling often indicative of shock or blood pooling.

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28
Q

In what section do you ask the pt if they are experiencing any chest pain?

A

During the cardiovascular system.

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28
Q

What are some causes of Edema?

A
  • Medications
  • Pregnancy
  • Infections
  • Other medical problems
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29
Q

How do you check the temp of the pt’s extremities?

A

Use the dorsum of the hand or fingers to assess.

30
Q

What is +1 of a pt. pulse?

A

Thready

31
Q

What is +2 of a pt. pulse?

A

Expected (normal)

32
Q

What is +3 of a pt. pulse?

A

Full (strong)

33
Q

What is +4 of a pt. pulse?

A

Bounding

34
Q

Describe Crackles

A
  • Moisture in the alveoli
  • Popping
35
Q

What are causes of Crackles?

A

CHF
Pneumonia
Pulmonary fibrosis

35
Q

Describe Wheezes

A
  • Constricted airways
  • Musical
36
Q

What causes wheezes?

A
  • Asthma
  • Foreign bodies
  • Pulmonary edema
  • Mucosal edema
37
Q

What are the forms of Adventitious breath sounds?

A
  • Crackles
  • Rhonchi
  • Wheezes
  • Stridor
38
Q

Describe Rhonchi

A
  • Airway obstruction secondary to mucus
  • Snore
39
Q

What are some causes of Rhonchi?

A
  • COPD
  • Pneumonia
  • Bronchiolitis
  • Cystic Fibrosis
40
Q

Describe Stridor

A
  • Swelling or obstruction in the airway
  • Heard on Inspiration (high pitched/honking)
  • Croup, epiglottitis
41
Q

Define Consolidation

A
  • Solid lungs
42
Q

What are some characteristics of Consolidation?

A
  • Increased density
  • Acinar shadow
  • Silhouette sign
  • Air bronchogram
43
Q

When would you use the voice transmission test.

A
  • to recognize consolidation in the lungs.
  • When fluid or sold masses replace air in the lungs, sounds will be transmitted more clearly.
44
Q

Describe Bronchoveiscular Breath Sounds.

A
  • Medium-Pitched
  • Equal inspiratory and expiratory phase
45
Q

Where is the best place to hear Bronchoveiscular Breath Sounds?

A

_ Heard best over the 1st and 2nd ICS next to the sternum and between the scapula.

46
Q

Describe Vesicular Breath Sounds.

A
  • Soft, low pitched, breezy sounds
  • Longer inspiratory phase and shorter expiratory phase.
47
Q

Where do you listen for Vesicular Breath Sounds?

A

Over the lung fields

48
Q

What causes Bronchovesicular Breath sounds?

A

Aire moving through the large airways of the bronchi.

49
Q

What causes vesicular Breath Sounds?

A

Air moving through the smaller airways

50
Q

What do you check with Muscle strength?

A
  • Grip strength
  • Plantar flex against resistance
  • Note if strength is equal bilaterally.
51
Q

What do you check for a neurovascular check?

A
  • Circulation
  • Motor
  • Sensory
51
Q

Describe Hypoactive bowl sounds.

A
  • Very fait
  • Infrequent (fewer than 5 sounds per min).
51
Q

Describe Hyperactive bowl sounds

A
  • Loud
  • Rushign sounds occuring every 2-3 seconds
52
Q

Describe Absent bowl sounds

A

Must listen for 5 minutes

52
Q

What characteristics of urine do you ask?

A

1) Color
2) Transparency
3) Odor

53
Q

What do us as the pt regarding urination ?

A

1) Pain or burning
2) Urgency/Frequency
3) Unable to fully empty

53
Q

What do you check for on a PureWick/Foley catheter?

A
  • Patency
  • Postiion of drainage bag
  • Amount of urine
53
Q

How do you assess for COLDERRA of pain.

A
  • Characteristics: sharp, dull, ache,
  • Onset: when did it start?
  • Location - Specific
  • Duration: how long does it last?
  • Exacerbation: What makes it worse?
  • Relief: What makes it better?
  • Radiation: Does it go anywhere else?
  • Accompanying signs and symptoms (nausea, blurred vision.)
54
Q

Describe what Pallor skill looks like

A
  • Light Skinned pts: White, loss of pick or yellow tones.
  • Dark-skinned pts: Loss or red tones
55
Q

Describe what Cyanosis skin looks like.

A

A blue gray color to the skin described as ashen

56
Q

Describe what Jaundice skin looks like.

A

A yellow-orage hue to the skin

57
Q

Describe what Flushing skin looks like

A

A widespread, diffuse area of redness

58
Q

Define Erythema

A

a reddend are

59
Q

Define Ecchymosis

A

Bruisded are (blue-green-yellow)

60
Q

Define Petechiae

A

Tiny, pinpoint red or reddish-purple spots

60
Q

When checking a wound site, what are you looking for/at?

A

1) Signs of healing
2) Closure device
3) Any s/s of infection

61
Q

What does “turgor” refer to?

A
  • Elasticity of the skin
  • How hydrated a pt is
62
Q

What do you look at when looking at the integrity of the skin?

A
  • For any open wounds
  • Rashes
  • Bruises
  • Is skin clean, dry, and intact (CDI)
63
Q

What are the different types of IVs?

A
  • Peripheral (PIV)
  • Central Line (CVC)
  • Saline lock (SL)
64
Q

Describe phlebitis w/ symptoms

A
  • Inflammation of the wall of your view
  • Symptoms include pina, redness, and swelling near the vein.
  • Symptoms may appear when you are receiving an IV medication, or 48 to 96 hours after you receive the medication
64
Q

Describe infiltration w/ symptoms.

A
  • Happens when the catheter goes through or comes out of your vein.
  • The IV fluid then leaks into the surrounding tissue.
  • May cause pain, swelling and skin that is cool to the touch

1030 Fundamental (4 decks)

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