Day 3 - Patient Assessments Flashcards
Neuro, respiratory, cardiac, GI, GU, skin, drains
What are cranial nerves 3, 5, 7, 9, 10, 11, 12, and what do they control?
CN III Oculomotor
*
CN V Trigeminal
*
CN VII Facial
*
CN IX (9) Glossopharyngeal
*
CN X Vagus
*
CN XI (11) Spinal Accessory
*
What are the components of GCS?
Eye opening: E1-4
Verbal response: V1-5 (T)
Motor response: M1-6
Decorticate vs. decerebate
Decorticate
* abnormal flexion
* elbows/wrists bent
Decerebrate
* abnormal extension
* elbows straight/wrists bent
* worse on GCS
What are the 3 subtypes of delirium?
Hypoactive - decreased LOC
Hyperactive - agitiation
Mixed - fluctuates
What does Central pain vs. peripheral pain assess?
Central pain assesses arousal and higher levels of brain function.
Peripheral pain is used to assess eye opening, may ilicit spinal reflex: not good for motor response
What are 3 pain assessment tools?
Visual scale - they identify a face that they relate to
Numeric rating scale - they rate their pain 1-10
Behaviour Pain Scale CPOT - they are unable to explain, we assess based on behaviour
What are 2 pain and sedation assessment tools?
Sedation Agitation Score (SAS)
* 1 (unarousable) - 7 dangerously agitated
Richmond agitation sedation scale (RASS)
* -5 (unarousable) - +4 danger to staff, violent
What are the two delirium assessment tools?
Intensive care delirium screening checklist (ICDSC)
* 1-8 total points
* 4+ is positive
Confusion assessment method for ICU (CAM-ICU)
* 4 features
* positive when both 1-2 are + plus 3 OR 4
What are the anterior respiratory landmarks? Where?
Suprasternal notch - superior sternum
Angle of Louis - below sternum
Medistinal line - midline chest
Midclavicular line - midclavicle down
Midaxillary line - armpit down
2nd rib
Lung boundaries
What are the normal breath sounds?
Bronchial
Bronchovesicular
Vesicular
What are the cardiac landmarks?
A PEt Monkey
Aortic
Pulmonic
Erbs point
Tricuspid
Mitral
Normal vs. abnormal heart sounds
explain how they are made
Normal: S1 (closure of mitral and tricuspid valves) & S2 (closure of aortic and pulmonic valves)
Abnormal
S3 (can be norm. for young patients)
* heard after S2
* rapid early filling in diastole with rush of blood hitting noncompliant ventricle
* SLOSH-ing-in
S4
* heard before S1 & S2
* atrial kick pushes blood into noncompliant ventricle
* a-STIFFF-wall
Murmurs, pericardial friction rub, bruits
Differentiate murmurs, pericardial friction rub, bruits
Murmurs
* turbulent blood flow caused by valves, defects, dilated chambers
Pericardial friction rub
* grating sound
* inflammation of the pericardium
* heard most at Erbs point
* caused by MI, cardiac surgery
Bruits
* swishing sound
* narrowing/partial obstruction of an artery = turbulent flow
What are the abdominal quadrants?
Separated by a cross over the umbilicus
RLQ, RUQ, LUQ, LLQ
What organs are in each quadrant?
RUQ
* duodenum
* liver
* gallbladder
* transverse colon
* small intestine
* right kidney
RLQ
* appendix
* ascending colon
* small intestines
* rt ureter
* reproductive organs
* fallopian tube, ovary, spermatic cord
LLQ
* descending colon
* sigmoid colon
* small intestine
* left ureter
* reproductive organs
LUQ
* stomach
* pancreas
* spleen
* transverse colon
* left kidney