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Module 2 (Skills) > Focused Assessments > Flashcards

Focused Assessments Flashcards

1
Q

ABC assessing

A

Airway
Breathing
Circulation

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2
Q

Why is a focused assessment performed?

A

when the patient has an illness related to a body system, or when they complain of specific symptoms

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3
Q

What is focused or problem-oriented assessment?

A

consists of a thorough assessment of a particular health problem and do not cover areas not related to the problem
- already been identified
- Narrow
- status
- new or overlooked/misdiagnosed

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4
Q

Focused Neurological Assessment
- Areas

A
  • rapidly identifying any impairment in a person’s response to the environment
    ~ 4 General Areas
    LOC
    sensory (soft/blunt) and motor function (grasps/walking)
    pupillary changes and extraocular mvmt
    VS and respiration patterns
    ~ Also
    hallucinations, delusions, delirium, or seizure activity
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5
Q

What questions should you ask about HEADACHES?

A

Ask when?
Ask history of HA?
Is there any medication that helps?
Do you have nausea, blurred vision or visual changes?

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6
Q

S/S of nervous system disorders

A

Persistent or sudden onset of a headache.
A headache that changes or is different.
Loss of feeling or tingling.
Weakness or loss of muscle strength.
Loss of sight or double vision.
Memory loss.
Impaired mental ability.
Lack of coordination.
Abnormal VS

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7
Q

Assessing the LOC

A

what is the date? Who is the president? What is going on in the news today? Where are you?

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8
Q

Assessing sensory and motor functions

A

use of qtip – cotton versus sharp
HG; TW – gait

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9
Q

Assessing pupillary

A

what is normal size for pupils?
2-4mm in diameter in bright light
4-8 mm in dark

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10
Q

When should you perform a neurological assessment?

A

Headaches
Loss of sensory/motor functions
double vision
spinal cord
head trauma

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11
Q

Cardiac Focused Assessments

A

rapidly identify any irregularities in cardiac function

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12
Q

Listen to the heart valves for

A

quality of rate and rhythm
any abnormal sounds
apical pulse
chest pain?
abnormal sounds like clicks, rubs, extra beats

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13
Q

5 Places of Heart Sounds
Diaphragm then bell

A

Aortic (2nd intercostal right)
Pulmonic (2nd intercostal left)
Erb’s Point (3rd)
Tricuspid
Mitral (Apex/Apical)

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14
Q

What side of the stethoscope, do you use to check heart sounds

A

Diaphragm then bell

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15
Q

Mneumonic for 5 Heart Places

A

All
People
enjoy
Time
Magazine

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16
Q

Erbs is located

A

3rd intercostal space

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17
Q

Where is the apical pulse located?

A

Mitral

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18
Q

If you hear 3+ heartbeats, what does that usually mean?

A

heart failure

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19
Q

Respiratory Focused Assessments

A

Observe the patient for important respiratory clues: = signs of injury or devices
-Look for abnormalities in the shape of the patient’s chest.
-Check the rate of respiration and quality effort
- cyanosis or pursed-lip breathing
- Ask about the shortness of breath and watch for signs of labored breathing.
- Listen front and back
-Check the patient’s pulse and blood pressure.
-Assess oxygen saturation.

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20
Q

What are you assessing in a respiratory assessment?

A

checking the respiratory rate, the symmetry, depth and sound (auscultation) of breathing, observes for accessory muscle use and tracheal deviation

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21
Q

Peripheral Neurovascular Assessment

A

Compartment syndrome

22
Q

Leg compartments - Lower

A

anterior, lateral, superficial, and deep posterior

23
Q

Leg compartments - Upper

A

anterior (extensor), medial (adductor), posterior (sciatic n.)

24
Q

6 P’s indicating ischemia

A

Pain
Paresthesia
Pallor
Pulselessness (dorsalis pedis, posterior tibialis)
Poikilothermia (usually only for compartment syndrome)
Paralysis

25
Q

Poikilothermia

A
  • part of a muscle has too much pressure inside near a fracture
26
Q

Poikilothermia means

A

body/skin temperature

27
Q

Paresthesias

A

numbness, tingling

28
Q

Abdominal Focused Assessments assessed for

A

pain, nausea, vomiting, injury
changes in appetite or bowel habits
treatments
bowel sounds 5-30 per min
bruits
Bloating, blood in stool, constipation, diarrhea

29
Q

How do you assess the abdomen

A

Inspect/Look for scars, drains, tubes
auscultate/Listen
percuss
ANY discomfort or pain
Feel/palpate (palpate area of tenderness last)

30
Q

What other area besides quadrants do you want to assess/auscultate/palpate?
-Why?

A

Epigastric
-Bruits

31
Q

Bruits

A

not normal could indicate aortic aneurysm, renal artery stenosis or partial occlusion of the femoral arteries

32
Q

Bruits sound like

A

swishing sounds with visual pulsations

33
Q

Start abdominal auscultation in

A

RLQ

34
Q

Sign of peritoneal irritation

A

rebound tenderness
- If pain is present after skin rebounds back after pressing down

35
Q

The RLQ contains

A

the lower part of the kidney
part of ascending colon
cecum
vermiform
appendix
uterus
ovaries

36
Q

The RUQ contains

A

right lobe of liver
gallbladder
duodenum
bile duct
head of pancreas
kidney and adrenal gland
transverse colon part
ascending colon part

37
Q

LUQ contains

A

left lobe of liver
stomach
diaphragm
spleen with adrenal gland
kidney
duodenum
pancreas body
pancreatic duct
transverse and descending colon part

38
Q

LLQ contains

A

s. intestine
sigmoid colon
part of descending colon
umbilicus
rectum
bladder
anus

39
Q

Modified Early Warning Score’s primary purpose

A

prevent delay in intervention or transfer of critically ill patients

40
Q

When should you check MEWS?

A

every 4 hours

41
Q

MEWS Colors from normal to RRT

A

GREEN 0-3
Yellow 4
Orange 5
Red 6+

42
Q

Sepsis

A

body’s extreme response to an infections
Body’s own immune system attacks its very own tissues and organs in response to infection

43
Q

Without timely treatment sepsis can rapidly lead to

A

tissue damage
organ failure
death

44
Q

When assessing tubes and drains?

A

Know what kind of tube you are assessing
necessity for pt
follow all tubes, lines, and drains from insertion point to connection point
label all connections to minimize risk of misuse and to rapidly identify what they are

45
Q

Anything attached to pt, anything going in or coming out must be ________

A

assessed

46
Q

Assessing the Pain (PQRST)

A

Provoke (cause worsening improvement)
- what were you doing when the pain started?
- is the pain worse or has improved w/ or w/o intervention?
Quality (pt’s descriptive words: dull, sharp, crushing)
- Neuropathic
- Somatic
- Visceral
Radiate (localized or travel)
- down extremity or side
- stationary or referred
Severity (scale)
Time (onset, duration, frequency)
- chronic or acute

47
Q

Neuropathic pain is described as

A

burning, shooting, numb, fire, electrical, bugs crawling

48
Q

Somatic pain is described as

A

achy, throbbing, dull

49
Q

Visceral pain is described as

A

squeezing, pressure, cramping, dull, deep, stretching, distension

50
Q

Telemetry Lead Placement purpose
Not tested

A

Monitor the cardiac status of any patient at risk for a cardiac event or new onset of a cardiac dysrhythmia

Module 2 (Skills) (12 decks)

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