Baseline Assessment Procedure Flashcards
Before beginning the assessment what does the nurse need to do?
WIIPPE:
W - wash your hands + wear gloves
I - Introduce self
I - Identify pt
P - Provide privacy
P - Position pt.
E - Explain procedure
What two pt identifiers do nurses us and what do you check them against?
1) Pt name
2) pt D.O.B
Have pt tell you and check it against their wrist band.
What do you need to assess w/ the neurological system?
- Mental status
- Level of consciousness and orientation (LOC)
or - Glasgow
- Level of consciousness and orientation (LOC)
- Pupillary responses PERRLA
- Deficits
How do you test a level of consciousness (LOC)
A&O x 4 = Alert and oriented to
- Person
- Place
- Time
- Situation
Do you document both a LOC and a GCS?
No, do one or the other
What do you score for on a Glasgow Coma Scale?
- Eye opening response
- Best verbal response
- Best motor response
Describe the PERRRLA
Pupils are equal, round, reactive to light and accommodation.
- Direct and Consensual
- They should accommodate equally
What does it mean to have your pupils accommodate equally?
- pupils should constrict and eyes cross as a person attempts to focus on an item moving toward them.
- Distant = dilated
- Close = Constricted
What is the lowest you can get on a Glasgow Coma Scale (GCS)
3
What is the highest you can get on a Glasgow Coma Scale (GCS)
15
What neurological system deficits do you check for?
- Facial drooping
- Drooling
- Slurred speech
- Confusion
- Balance issues
- Muscle weakness
- Partial or complete paralysis
When a pt has head trauma what needs to be done.
A focused assessment.
What is a focused assessment?
- Assess LOC
- Vital signs
- PERRLA
- Assess strength of hand grip and movement of extremities.
- Determine sensation to touch/pain in extremities
What do you check for the cardiovascular system
- 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
What are the 5 areas for listening to the heart?
1) Aortic
2) Pulmonic
3) ERB’s Point
4) Tricuspid
5) Mitral
Where is the aortic valve?
Right 2nd intercostal space
Where is the pulmonic space?
Left 2nd intercostal space
Where is the ERB’s point?
(s,s) Left 3rd intercostal space
Where is the best place to listen to the Apical pulse
the Mitral valve
Where is the Tricuspid
Lower left sternal border 4th intercostal
Where do you listen to the Mitral?
Left 5th intercostal, medial to Midclavicular line
S1 and S2 are heard equally at what spot?
ERBs point
What circulation are you looking at w/ the cardiovascular system?
Peripheral circulation
Capillary refill should be less than what?
3 seconds
With skin color, what is a cause of Pallor
Shock or blood loss
With skin color, what does Cyanotic mean.
blue-gray
Poor oxygenation
W/ Skin color, what does mottling mean?
Blotchy marbling often indicative of shock or blood pooling.
In what section do you ask the pt if they are experiencing any chest pain?
During the cardiovascular system.
What are some causes of Edema?
- Medications
- Pregnancy
- Infections
- Other medical problems
How do you check the temp of the pt’s extremities?
Use the dorsum of the hand or fingers to assess.
What is +1 of a pt. pulse?
Thready
What is +2 of a pt. pulse?
Expected (normal)
What is +3 of a pt. pulse?
Full (strong)
What is +4 of a pt. pulse?
Bounding
Describe Crackles
- Moisture in the alveoli
- Popping
What are causes of Crackles?
CHF
Pneumonia
Pulmonary fibrosis
Describe Wheezes
- Constricted airways
- Musical
What causes wheezes?
- Asthma
- Foreign bodies
- Pulmonary edema
- Mucosal edema
What are the forms of Adventitious breath sounds?
- Crackles
- Rhonchi
- Wheezes
- Stridor
Describe Rhonchi
- Airway obstruction secondary to mucus
- Snore
What are some causes of Rhonchi?
- COPD
- Pneumonia
- Bronchiolitis
- Cystic Fibrosis
Describe Stridor
- Swelling or obstruction in the airway
- Heard on Inspiration (high pitched/honking)
- Croup, epiglottitis
Define Consolidation
- Solid lungs
What are some characteristics of Consolidation?
- Increased density
- Acinar shadow
- Silhouette sign
- Air bronchogram
When would you use the voice transmission test.
- to recognize consolidation in the lungs.
- When fluid or sold masses replace air in the lungs, sounds will be transmitted more clearly.
Describe Bronchoveiscular Breath Sounds.
- Medium-Pitched
- Equal inspiratory and expiratory phase
Where is the best place to hear Bronchoveiscular Breath Sounds?
_ Heard best over the 1st and 2nd ICS next to the sternum and between the scapula.
Describe Vesicular Breath Sounds.
- Soft, low pitched, breezy sounds
- Longer inspiratory phase and shorter expiratory phase.
Where do you listen for Vesicular Breath Sounds?
Over the lung fields
What causes Bronchovesicular Breath sounds?
Aire moving through the large airways of the bronchi.
What causes vesicular Breath Sounds?
Air moving through the smaller airways
What do you check with Muscle strength?
- Grip strength
- Plantar flex against resistance
- Note if strength is equal bilaterally.
What do you check for a neurovascular check?
- Circulation
- Motor
- Sensory
Describe Hypoactive bowl sounds.
- Very fait
- Infrequent (fewer than 5 sounds per min).
Describe Hyperactive bowl sounds
- Loud
- Rushign sounds occuring every 2-3 seconds
Describe Absent bowl sounds
Must listen for 5 minutes
What characteristics of urine do you ask?
1) Color
2) Transparency
3) Odor
What do us as the pt regarding urination ?
1) Pain or burning
2) Urgency/Frequency
3) Unable to fully empty
What do you check for on a PureWick/Foley catheter?
- Patency
- Postiion of drainage bag
- Amount of urine
How do you assess for COLDERRA of pain.
- 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.)
Describe what Pallor skill looks like
- Light Skinned pts: White, loss of pick or yellow tones.
- Dark-skinned pts: Loss or red tones
Describe what Cyanosis skin looks like.
A blue gray color to the skin described as ashen
Describe what Jaundice skin looks like.
A yellow-orage hue to the skin
Describe what Flushing skin looks like
A widespread, diffuse area of redness
Define Erythema
a reddend are
Define Ecchymosis
Bruisded are (blue-green-yellow)
Define Petechiae
Tiny, pinpoint red or reddish-purple spots
When checking a wound site, what are you looking for/at?
1) Signs of healing
2) Closure device
3) Any s/s of infection
What does “turgor” refer to?
- Elasticity of the skin
- How hydrated a pt is
What do you look at when looking at the integrity of the skin?
- For any open wounds
- Rashes
- Bruises
- Is skin clean, dry, and intact (CDI)
What are the different types of IVs?
- Peripheral (PIV)
- Central Line (CVC)
- Saline lock (SL)
Describe phlebitis w/ symptoms
- 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
Describe infiltration w/ symptoms.
- 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
