CP: POD #2 Flashcards
1
Q
Physical Assessment Techniques (4 basic)
A
- inspection
- palpation
- auscultation
- olfaction
2
Q
when to perform head to toe assessment
A
- performed at the beginning of each shift
- establish baseline and detect abnormal findings
- systemic matter (from head to toe)
3
Q
neurological assessment (6 things)
A
- Level of consciousness
- orientation (confusion: who, where, date)
- glasgow coma scale (pts with head injury: ex: stroke)
- PERRLA
- motor strength
- pain
4
Q
Glasgow coma scale
A
- neurological status overtime
- higher score = better neurological function
- out of /15
- motor: drift, feet (plantar/dorsi), wiggle, grip, squeeze
- eye
- verbal
5
Q
LOTTAARP
A
location
onset
time
type
associated symptoms
Alleviating factors
radiating
precipitating event
6
Q
PERRLA
A
- pupils equal
- equal
- round
- reactive to
- light
- Accommodation
- size (1-10mm)
7
Q
pain assessment
A
- numerical, descriptive, or visible
-LOTTAARP
-OPQRSTUV - 1-10 (1 no pain-10 worst pain possible)
- behavioural/nonverbal pain indicators
8
Q
Respiratory Assessment
A
- respiratory rate, rhythm, effort, use of accessory muscles
- cough & sputum
- chest ausultation
- SOB/dyspnea
- oxygen deliver system
- oxygen saturation
9
Q
clinical signs of SOB/dyspnea
A
- exaggerated respiratory effort
- use of accessory muscles of respiration
- nasal flaring
- increased rate and depth of respiration
10
Q
cough
A
- sudden audible
11
Q
chest auscultation
A
- hearing for breath sounds
- air entry
12
Q
what causes wheezing?
A
- tightening of the bronchioles and the movement air
- caused by high velocity airflow thru severely narrow or obstructed airway
13
Q
what causes crackling?
A
- mixture of narrowing of the bronchioles build up of fluid in the lungs
- movement of the fluid between
- can be barely noticeable or coarse
14
Q
cyanosis
A
- low oxygenation of tissues
- results in blue discolouration of skin and mucous membranes
15
Q
central cyanosis
A
- tongue
- soft palate
- conjunctiva of eye
- late stage: centrally look pale > body has taken blood from extremities
16
Q
peripheral cyanosis
A
- extremities
- nail beds
- earlobes
- see it first in fingers and toes
17
Q
respiratory distress
A
- SOB
- use of accessory muscles
- appearing
18
Q
nursing interventions to improve respiratory functioning
A
- orthopneic position
- deep breathing and coughing
- elevate head of bed
19
Q
orthopneic position purpose
A
- Sitting up right
- Leaned slighting over
- Tripod position
- Limber
- Raise the head of the bed (high fowlers)
- Deep breathing/coughing
20
Q
benefits of deep breathing and cough
A
- facilitates/mobilizes secretions the exchange of co2 and o2
- increases lung expansion
- can prevent pneumonia and atelectasis
21
Q
what is atelectasis
A
complete or partial collapse of entire lung or area (lobe)
22
Q
Cardiovascular assessment
A
- 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
23
Q
how do you apply capillary refill
A
- 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
