CEC Session 1

Question 1

What are the two basic components of the physical exam?

Answer 1

Subjective data, objective data

Question 2

Subjective Data

Answer 2

What the patient says about himself or herself

Question 3

Objective Data

Answer 3

What you observe about the patient through measurement

• There should be subjective data to go with every objective finding

Eg: radial pulse (objective)
Do you ever feel as if your pulse is fast or running slow or maybe it sometimes misses a beat? (Subjective)

Question 4

PQRSTU

Answer 4

Pain assessment technique

P: provokes- what causes pain? What makes it better? What makes it worse?
Q: quality- what does it feel like? Sharp, dull, stabbing, burning, crushing?
R: radiates- where is the pain and does the pain radiate?
S: severity- how severe is the pain on a scale of 1-10? Has it changed?
T: time- time pain started? How long did it last? Constant or does it come and go?
U: understanding- what do you think is going on?

Question 5

Quantify the scale of the pain/ symptom severity tool

Answer 5

0- pain
1-3: mild pain
4-6: moderate pain
7-10: severe pain

Question 6

WILDA

Answer 6

Pain assessment tool

W: words to describe- aching, stabbing, tender, numb, cramping, throbbing, etc.
I: intensity- how severe is the pain on a scale of 1-10? Has it changed?
L: location- where is the pain?
D: duration- is the pain always there? Does it come and go? When did it start?
A: aggravating and alleviating factors- what makes the pain better? What make the pain worse?

Question 7

SBAR

Answer 7

Physican report tool

S: situation- identify yourself, unit, patient, problem, why are you calling, reason fro communication, briefly describe the problem
B: background- diagnosis, medical history, vital signs (change from baseline), allergies, medications, pertinent labs, IV fluids
A: assessment- what do you think the problem is, areas of concern, interventions
R: recommendations- what is your recommended action/ intervention for the patient

Question 8

Universal Competencies

Answer 8

Introduce self
State purpose
Ask the patient what they would like to be called
Ascertain that patient is comfortable
Provide privacy (mime)
Hand hygiene
Double identifiers
Allergies
Documentation