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Patient Assessment > DAY 1 PM > Flashcards

DAY 1 PM Flashcards

1
Q

Screening Recommendations

A

-Physical exam preformed
2 years for adolescent (12-19) and adults >60
4-6 years for adults (20-59)

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2
Q

Sequence & and exam technique

A
  • Head to toe
    1. Inspection
    2. Palpation
    3. Percussion
    4. Auscultation
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3
Q

Inspection

A

Visual evaluation

  • Use senses to form an opinion that will aid in decision making
  • Watch everything they do, and the way they talk/behave
  • ID presence of bruises, lumps, lesions/changes in skin and nail color.
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4
Q

Palpation

A
  • Touching or feeling with your hands
  • Allows you to assess position, size and SHAPE, mobility and consistency of a body region
  • May detect fluid in a space
  • Uncovers organs that are enlarged or abnormal.
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5
Q

Discrimination of findings

A
  • Use fingertips for tactile discrimination
  • Use back of hand (dorsum) to measure T
  • Use palmar aspects of MCP’s or ulnar surface to detect vibration.
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6
Q

Depth of palpation

A
  • Light palpation: assess surface and muscle lesions
  • Medium palpations: asses lesions, masses, tenderness, pulsations and pain ( press 1-2cm into the region)
  • Deep palpations: assess organ (use one hand on top of the other to press 2-4cm into the region in a circular pattern)
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7
Q

Percussion

A
  • Striking the body surface lightly but sharply

- Determines size, position and DENSITY of the underlying structure as well as fluid or air in a cavity.

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8
Q

Five percussion sounds

A
  • Flat (Sternum and thigh)
  • Dull (liver)
  • Resonance (healthy lung)
  • Hyper resonance (emphysema lung)
  • Tympani (gastric air bubble)
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9
Q

Auscultation

A

-Use a stethoscope to detect the body sounds created by the heart lungs, blood vessels and abdominal viscera.

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10
Q

Bell of stethoscope

A
  • Amplifies low pitch sounds

- Heart murmurs, arterial/venous turbulence, bruits.

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11
Q

Diaphragm of stethoscope

A
  • Amplify high pitch sounds

- Breath, bowel, voice and regular heart sounds. BP also*

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12
Q

Hand hygiene

A
  • WASH HANDS before and after
  • Hand wash with plain soap and h20 or antibacterial soap
  • Can use EtOH based products if hands aren’t dirty
  • Change gloves in btwn procedures and tasks
  • NO long nails
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13
Q

General assessment

A

Quick assessment of pt appearance, behavior and mobility

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14
Q

Physical parameters

A

Height: pt to stand erect without shoes against flat vertical surface 1in=2.54cm
Weight: measure weight 1lbs=2.2kg and find BMI = kg (weight) /m2 (height)

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15
Q

Weight class for adults

A

40 obese 3 (morbid)

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16
Q

Waist circumference

A

-Correlated with abdm fat content, risk factor for cardiac fail. place tape just above hipbone and measure just after you breathe out.
Men > 40in
Women > 35 in

17
Q

Vital signs

A
  • Pulse (HR)
  • BP
  • RR
  • Temp
  • Pain*
18
Q

Temperature

A

-Regulated by the HPA
-Normal adult range is 97.5-99.0F average of 98.6F
C=5/9 x (F-32)
-Hyperpyrexia >106F
-Hypothermia <95 F

19
Q

Fever

A
  • Elevation of body temp that exceeds normal daily variations
  • Clinically >100.4 F
  • Chills and shaking suggest bacteremia as body tries to raise the temp
  • Sweating is the body’s response to lower the temp
  • Ask about traveling, contacts with sick people, medications like NSAIDs and APAP (they reduce fever)
20
Q

Pulse/HR

A
  • Peripheral pulses assess HR, rhythm and function
  • Radial pulse most common to assess
  • Adults normal HR is 60-100 bpm
  • bradycardia less than 60 bpm
  • tachycardia greater than 100 bpm
21
Q

Pulse rhythm

A

-Normal is steady and even
-Irregular pulses are arrhythmia
if irregular pulse is found listen to the apex of the heart for a more accurate reading with the stethoscope.

22
Q

Force or pulse

A
  • Normal pulse is easily palpated and does not fade in or our
  • Based on 4 point scale
    0: absent
    1: weak
    2: normal
    3: increased
    4: bounding/abnormal
23
Q

Respiratory Rate (RR)

A
  • Reported as rpm (respiration per min) count number of inhalation
  • Normal range 12-20 rpm
  • Bradypnea < 12
  • tachypnea >20
24
Q

Blood pressure

A
  • Force of blood as it push against the arterial walls
  • Systolic BP: max pressure felt on arteries during left ventricle contraction
  • Diastolic BP: resting pressure that the blood exerts between each ventricular contraction
25
Q

Selecting the BP cuff

A

Length of inflatable bladder of cuff should be about 80% of upper arm circumference.

26
Q

Measuring BP

A

-Ask pt. and document the use of caffeine and tobacco
-Pt. to sit in chair, back supported, arm bared and at heart level
-Begin after 5 min of rest
-Release air in cuff 2-3 mmHg per sec
-First heart beat is Systolic
-Point at which beat disappears is diastolic
listen until 20mmHG below diastole
-Record BP along with which arm used, position and size of cuff

27
Q

Korotkoff sounds

A

The five phases of BP

  1. faint clear tapping (systole)
  2. swooshing
  3. crisp more intense tap
  4. muffling
  5. cessation of sounds (diastole)
28
Q

Common Errors

A
  • Incorrect cuff size (small= false high, big= false low)
  • Arm not at heart level (below= high, above =low)
  • Deflation speed ( too fast= low Sys or high Dia, too slow = false high Sys)
29
Q

BP classifications

A
  • Pre hypertension 120-139 / 80-89 mmHg
  • Stage 1 hypertension 140-159 / 90-99
  • Stage 2 hypertension >160 / >100
30
Q

Orthostatic or postural blood pressure

A
  • Measure BP and HR in two different positions
  • BP at supine position after 10 min resting then again within 3 min of standing.
  • Normally: Sys drops slightly or remain the same upon standing and the Dias rise slightly
  • Ortho. hypotension is a drop in Sys >= 20mmHg or in distole > 10mmhg

Patient Assessment (4 decks)

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