Chapter 13 Flashcards
Essential Skills of Patient Assessment
-Observation
-Evaluation
-Assessment
-Communication
-Relaying information
AIDET communication too stands for:
-Acknowledge
-Introduce
-Duration
-Explanation
-Thanks
Warmly greet the patient by name
Acknowledge
Tell the patient who you are (name, title, length of time in the profession) and what you will be doing for them.
Introduce
Explain how long the examination will take, and frequently update the patient of any delays
Duration
Describe the examination the patient will be undergoing. This is the opportunity to collect pertinent history.
Explanation
Express gratitude to the patient for choosing your facility for his or her care, for exhibiting patience, for being positive throughout the examination, and so forth
Thanks
Questioning Techniques for Taking a History
- Open-ended questions
- Facilitation
- Silence
- Reflection or reiteration
- Clarification or probing
- Summarization
What are the elements of a history
-Onset
-Duration/chronology
-Specific location
-Quality of symptoms
-Severity of pain
-What aggravates/alleviates
-Associated manifestations
Onset sampling questions
How did it start? What happened? When did it first trouble you? Was it sudden or a complaint that gradually got worse?
Duration/Chronology sampling questions
Have you ever had it before? Has it been continuous? Does it bother you all the time? How long has this attack been bothering you?
Specific location sampling questions
Where does it hurt (or where is the problem)? Can you put your finger on where it hurts the most? Does it hurt anywhere else?
Quality of symptoms sampling questions
What does it feel like? Sharp, stabbing pain? Dull ache? Throbbing pain?
Severity of pain sampling questions
How severe is it? Mild, moderate, or severe? (Some like to use a pain scale of 0 to 5 or 0 to 10, with 0 being no pain at all and the highest number representing the worst pain the patient can imagine.) Does it wake you up at night?
What aggravates/alleviates sampling questions
What seems to make it worse? When is it worst? Is it worse after meals? At night? When you walk? What has helped in the past? Does that still help? What seems to help now? Does the time of day (amount of rest, change in position, and so on) make a difference?
Associated manifestations sampling questions
Are there any other symptoms that you are experiencing that may be related to your chief complaint?
Is often the first and primary observer of a significant change in the patient’s current condition
radiographer
Assessing Current Physical Status
-Checking the chart
Obtain more specific information.
-Physical assessment
An ongoing process of observation, comparison,
and measurement of patient’s condition before,
during, and after imaging procedures
-Vital signs
Temperature, pulse rate, respiratory rate, and
blood pressure
Color code wristband for allergy
red
Color code wristband for fall risk
yellow
Color code wristband for DNR
purple
A patient with a previous history of allergies is sometimes referred to as
allergenic individual
The most important process in patient assessment is sometimes called
eyeballing the patient
Physical Apperance and Responses
-Skin color
-Temperature
-Level of consciousness (LOC)
-Breathing
Denotes a bluish coloration in the skin and indicates a lack of sufficient oxygen in the tissues. This is most easily seen in the mucous membranes, such as the lips or the lining of the mouth.
Cyanotic
Cold sweat
Diaphoretic
Hot, dry skin may indicate a
fever
Can cause cool, moist skin with wet palms and shaking hands
Acute anxiety
What are the 4 levels of consciousness
- Alert and conscious
- Drowsy but responsive
- Unconscious but reactive to painful stimuli
- Comatose
is a seizure disorder without convulsions that can cause a brief loss of consciousness without warning
Absence (petit mal seizure)
Normal breathing is considered
quiet and calm
A form of chronic obstructive pulmonary disease that prevents patients from exhaling effectively, limiting their capacity for inhaling fresh air
Emphysema
is the term for an inability or serious difficulty in breathing when lying flat
Orthopnea
They involve the measurement of temperature, pulse rate, respiratory rate, and blood pressure
Vital signs
An instrument for indirect measurement of blood pressure. It consists of an inflatable cuff that fits around the arm, a bulb for controlling air pressure within the cuff, and a mercury or aneriod manometer
Sphygmomanometer
Body temperature is lowest in
the morning
Body temperature is the highest in
the evening
Temperatures may be obtained by:
oral, rectal, axillary, tympanic and temporal artery routes
Inserted into external ear canal
Tympanic temperature probe
contain an infrared sensor that measures the temperature over the temporal artery in the region of the forehead. The gentle scan across the forehead and temporal region is easily and quickly accomplished and is not objectionable to patients. Research indicates that this method is more consistently accurate than the tympanic method.
Temporal artery thermometers
Medical term for fever
Pyrexia
Is a sign of increased body metabolism usually in response to an infectious process
Fever
Normal adult temperature range is
97-99 degrees Fahrenheit
Average oral temperature is
98.6 degrees Fahrenheit
Fever is typically considered greater than
100.4 degrees Fahrenheit
the advancing pressure wave in an artery caused by the expulsion of blood when the left ventricle of the heart contracts.
Pulse
The heart rate is measured in
beats per minute (bpm)
The most common site for palpation of the pulse is
The radial artery
Why can’t you take a accurate pulse using your thumb
Because your own thumb has a pulse
If the radial pulse is weak or difficult to count you will do (blank) instead
Carotid artery
This pulse may be significant when there is a question of compromise in the peripheral circulation
The dorsalis pedis or pedal pulse
A measurement taken by listening to the heartbeat through a stethoscope placed over the apex of the heart
apical pulse
abnormally rapid pulse occurs when the heart rate is greater than 100 bpm
Tachycardia
Average normal pulse rate in adults
60 bpm and 100 bpm
Heart rate that is too slow; less than 60 bbpm
Bradycardia
Normal range in adults of breaths per minute
12 to 20 breaths/minute
Slow breathing with fewer than 12 breaths/min
Bradypnea
More than 20 breaths/min
Tachypnea
Difficult in breathing
Dyspnea
inflammation of the pleura causing adhesions between the lungs and the chest wall
Pleurisy
Cessation of breathing (stops or restarts)
Apnea
Abnormally high blood pressure
Hypertension
Abnormally low blood pressure
Hypotension
Patients in (blank) exhibit a significant increase in pulse rate and respiratory rate
Shock
Term that means “not wet” or without liquid
aneroid
The top figure is the (blank) pressure and is a measure of the pumping action of the heart muscle itself
systolic pressure
The bottom figure is (blank) pressure and indicates the ability of the arterial system to accept the pulse of blood forced into the system when the left ventricle contracts
diastolic pressure
Normal range for systolic
95 to 119 mm Hg
Normal range for diastolic
60 to 79 mm Hg
Normal range for blood pressure is
120/80 mm Hg
Stage 1—systolic ranges 140–159 mm Hg; diastolic
ranges 90–99 mm Hg
Stage 2—the most severe form
Systolic reading is 160 mm Hg or greater and diastolic is 100
mm Hg or greater.
Hypertension
Diastolic pressure <50 mm Hg or systolic
pressure <90 mm Hg
May also indicate shock
Hypotension
Common Laboratory Tests for Patient Assesssment
Complete Blood Count
Erythrocyte Sedimentation Rate
Blood-Clotting Assessments
Blood-Chemistry Tests
The most common pulse points are
Temporal, Carotid, Apical, Femoral, Brachial, Radial, Popliteal, Posterior tibial, and Dorsalis pedis
fluid loss
Dehydration
A blood clot formed on the wall of a vessel is called
Thrombus
A thrombus formed in a large vessel sometimes detaches from the vessel wall, becoming a free-floating clot
Embolus
Placed on a finger, toe, or earlobe, where it
continuously monitors both pulse rate and blood
oxygen levels
Pulse oximeter
Normal waveform
Sinus rhythm
One comprehensive way to monitor cardiac
activity; provides continuous measurement of
heart rate and blood pressure
Arterial catheter
Device that measures the electrical activity of
the heart; displays the information graphically in
the form of waves on a paper tracing or on a
monitor
Electrocardiograph monitor
Device that records or monitors the electrical
activity of the brain
Electroencephalography
