CP: POD #2 Flashcards
Physical Assessment Techniques (4 basic)
- inspection
- palpation
- auscultation
- olfaction
when to perform head to toe assessment
- performed at the beginning of each shift
- establish baseline and detect abnormal findings
- systemic matter (from head to toe)
neurological assessment (6 things)
- Level of consciousness
- orientation (confusion: who, where, date)
- glasgow coma scale (pts with head injury: ex: stroke)
- PERRLA
- motor strength
- pain
Glasgow coma scale
- neurological status overtime
- higher score = better neurological function
- out of /15
- motor: drift, feet (plantar/dorsi), wiggle, grip, squeeze
- eye
- verbal
LOTTAARP
location
onset
time
type
associated symptoms
Alleviating factors
radiating
precipitating event
PERRLA
- pupils equal
- equal
- round
- reactive to
- light
- Accommodation
- size (1-10mm)
pain assessment
- numerical, descriptive, or visible
-LOTTAARP
-OPQRSTUV - 1-10 (1 no pain-10 worst pain possible)
- behavioural/nonverbal pain indicators
Respiratory Assessment
- respiratory rate, rhythm, effort, use of accessory muscles
- cough & sputum
- chest ausultation
- SOB/dyspnea
- oxygen deliver system
- oxygen saturation
clinical signs of SOB/dyspnea
- exaggerated respiratory effort
- use of accessory muscles of respiration
- nasal flaring
- increased rate and depth of respiration
cough
- sudden audible
chest auscultation
- hearing for breath sounds
- air entry
what causes wheezing?
- tightening of the bronchioles and the movement air
- caused by high velocity airflow thru severely narrow or obstructed airway
what causes crackling?
- mixture of narrowing of the bronchioles build up of fluid in the lungs
- movement of the fluid between
- can be barely noticeable or coarse
cyanosis
- low oxygenation of tissues
- results in blue discolouration of skin and mucous membranes
central cyanosis
- tongue
- soft palate
- conjunctiva of eye
- late stage: centrally look pale > body has taken blood from extremities
peripheral cyanosis
- extremities
- nail beds
- earlobes
- see it first in fingers and toes
respiratory distress
- SOB
- use of accessory muscles
- appearing
nursing interventions to improve respiratory functioning
- orthopneic position
- deep breathing and coughing
- elevate head of bed
orthopneic position purpose
- Sitting up right
- Leaned slighting over
- Tripod position
- Limber
- Raise the head of the bed (high fowlers)
- Deep breathing/coughing
benefits of deep breathing and cough
- facilitates/mobilizes secretions the exchange of co2 and o2
- increases lung expansion
- can prevent pneumonia and atelectasis
what is atelectasis
complete or partial collapse of entire lung or area (lobe)
Cardiovascular assessment
- BP and HR
- CWMS (colour, warmth, movement, and sensation) x 4 limbs
- capillary refill x 4 limbs
- chest discomfort, pressure or pain
- edema: fluid build up (found in pts with HF)
- skin colour, moisture
- pulses
how do you apply capillary refill
- use nail beds and apply pressure
- goes from white to red
- less than 3 secs
- < 3 secs = sluggish: any vascular disease/how well our body is perfusing
signs of heart attack
- dull
- tingling down arm
- pain in the back
- chest sharp/pain
scale of pitting edema and the depth
- +1 2mm depth
- +2 4mm “
- +3 6mm “
- +4 8mm “
pulse sites
- dorsalis pedis (top of foot)
- posterior tibialis (inner ankle)
- femoral
- apical
- carotid
- brachial
- radial
- ulnar
Neurovascular Assessment
- sensory and motor function
- peripheral circulation
what can be used to chart CWMS
Peripheral neurovascular assessment record
who needs a neurovascular assessment
- fracture
- cast
- orthopedic
- spinal surgery
- signs of infection of limb
- circumferential burns
- restrictive dressing
why is it important for early detection of impaired blood flow or damaged nerves
- prevents permanent deficits
- loss of a limb
- death
what is CWMS
- colour
- warmth
- movement
- sensation
what happens when you have a cast
- swelling
- filling of capillaries (capillary refill)
- tight
when do we auscultate latte the brachial
only during blood pressure
when palpating pulse for strength use
0+-4+ (2+ normal)
where does temperature fall under in terms of vitals
neuro
abdomen inspection
- flat/round/distended
- bruising/scars/symmetry
abdomen auscultation
bowel sounds (active/hypo/hyperactive
abdomen palpation
- soft/firm/hard
- tender/non tender
what does gastrointestinal assessment include
- abdomen inspection
- abdomen auscultation
- abdomen palpation
- asses for:
- nausea and vomiting
- appetite
- dietary or fluid restriction
- continence/incontinence
- last bowel movement
how do we do the GI assessment
- follow the large intestine
- from right lower
- right upper
- left upper
- left lower
whats a normal GI sound
5-20 seconds you should hear some sounds
whats a hypoactive GI sound
< 5 sounds/min
- not hearing enough
- constipation
- distented
whats a hyperactive GI sound
> 35 sound/min
- diarrhea
0 sound after 5 mins
absence of bowel sound
when does abdomen palpation occur
after abdomen auscultation
how do you do abdomen palpation
- use whole hand
- look at pt
what does the bristol stool chart include
- colour
- odor
- consistency
- frequency
- shape
- constituents
what is included in the genitourinary assessment
-inspection
-assess for:
- urinary frequency: urgency, dysuria, hesitancy, retention
-polyuria, oliguria, nocturia, and hematuria
- last void
- continence/incontinence
what is included in inspection (GU)
- urine amount
- colour
- clarity
- odor
urinary problems
- dysuria
- urinary incontinence
- hematuria
- urinary retention
fecal problems
- constipation
- diarrhea
- fecal incontinence
- impaction
- hemorrhoids
what does integumentary assessment include
- head to toe
- characteristics:
- skin colour
- tecture
- thickness
- turgor (how hydrated you are)
- temperature
- hydration
- hair and nails:
- fingers
- toes
- feet
- nails
- presence of:
- lesions
- rashes
- pressure injury
- dressing
- tubes (IV or drain)
what is a braden scale
- risk of pressure sores
- skin break down
mild to no risk (braden scale)
15-23
moderate risk (braden scale)
13-14
high risk (braden scale)
10-12
very high risk (braden scale)
6-9
risk factors/common skin problems (pressure sore risk)
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction and/or shear
