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Patient Assessment Kettering > General Patient Assessment > Flashcards

General Patient Assessment Flashcards

1
Q

Medication reconciliation

A

Ensuring a patient’s medication is as accurate and up to date as possible.

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2
Q

Medication Reconciliation time frame

A

Within 24 hours of admission to hospital

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3
Q

Lethargic,somnolent, sleepy patient

A

Consider sleep apnea or excessive O2 therapy in a COPD patient

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4
Q

Assessing the emotional state of a pt, what would be seen with anxiety?

A

watching every movement, respiratory distress, hypoxemia

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5
Q

Assessing emotional state, Panic

A

Severe hypoxemia, tension pneumothorax, status asthmaticus

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6
Q

6 Activities of daily living

A
  1. bathing with a sponge, bath, or shower
  2. eating
  3. Dressing
  4. Toilet Use
  5. Transferring.
  6. Urine and bowel continence
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7
Q

Assessing activities of daily living can be used to determine?

A
  1. Nursing home admission 2. need for home care providers 3. use of hospital services 4. living arrangments 5. use of physician services 6. insurance coverage 7. mortality
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8
Q

Scoring system used to assess activities of daily living?

A

Katz scoring system

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9
Q

Measuring subjective symptoms :

A

orothopnea general malaise dyspnea pain dysphagia

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10
Q

orthopnea

A

shortness of breathe EXCEPT when in an upright position

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11
Q

general malaise

A

feeling run-down, nausea, weakness, fatigue, headache, ELECTROLYTE IMBALANCE.

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12
Q

dyspnea

A

shortness of breath

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13
Q

pain

A

A reaction of a specific nervous tissue

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14
Q

Dysphagia

A

difficulty swallowing

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15
Q

Proper interview techniques

A

1 Ask open-ended questions. 2 communicate using simple language. 3 utilize pictures, diagrams, etc. for illiterate patients. 3 begin to identify the patients major problems

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16
Q

Assessment by inspection

A

what you can see, age, height, weight, nourishment, etc

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17
Q

Peripheral edema

A

presence of excessive fluid in the tissue known as pitting edema

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18
Q

Causes of peripheral edema?

A

Congestive heart failure Renal failure

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19
Q

Ascites

A

Accumulation of blood in the abdomen, generally caused by liver failure

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20
Q

Clubbing of fingers

A

caused by chronic hypoxemia, suggestive of pulmonary disease such as COPD. The thumb and first finger are affected

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21
Q

Venous distension

A

JVD, (jugular venous distention) Seen during exhalation in patients with obstructive lung disease and air trapping

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22
Q

Capillary refill

A

Indication of peripheral circulation Color should return in 3 seconds

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23
Q

Diaphoresis

A

.A state of profuse heavy sweating .Heart Failure ( recommend diuretics, positive inotropic agents like Digoxin.) .Fever ,infection ( recommend antibiotics) .Anxiety, nervousness ( recommend sedatives) .Tuberculosis/night sweats ( recommend antitubercular drugs )

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24
Q

Decrease in the color of skin

A

ashen, pallor

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25
Q

causes of decrease in the color of skin

A

anemia, acute blood loss, vasoconstriction via reducing blood flow

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26
Q

assessing skin integrity, look for:

A

pressure sores and ulcers evaluate skin around tracheotomy stoma

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27
Q

assessing chest configuration

A

straight spine, no leaning forward( kyphosis) or side to side ( scoliosis)

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28
Q

kyphosis

A

leaning forward spine, convex curvature of the spine

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29
Q

Scoliosis

A

Spine in S shape, side to side

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30
Q

4 critical life functions, in order of importance in an emergency

A
  1. ventilation
  2. oxygenation
  3. circulation
  4. perfusion
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31
Q

Pectus Carinatum

A

anterior protrusion of the sternum

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32
Q

signs vs symptoms

Signs:

A

Objective information

  • can be measured
  • color
  • pulse
  • edema
  • blood pressure ect…
33
Q

signs vs symptoms

Symptoms :

A

Subjective information

  • things the patient must tell you
  • dyspnea
  • pain
  • nausea
  • muscle weakness etc …
34
Q

Types of advanced directives

A
  • DNR ( Do not resuscitate) pt does not want cardiopulmonary resuscitation
  • DNI ( Do not intubate) pt does not want to be intubated
  • Living Will, describes what pt would want if they become critically ill
  • Durable Power Of attorney, legal document that names a person or agent responsible for making decisions on behalf of the pt
35
Q
A
36
Q

Pectus Excavatum

A

Depression of part of the entire sternum

37
Q

Kyphoscoliosis

A

A combination of scoliosis and kyphosis

38
Q

Barrell chest

A

increase in A-P diameter

39
Q

Symmetrical chest movement

A

Both sides move equal at the same time

40
Q

asymmetrical chest movement

A

unequal movement. May indicate

  • post lung resection, post pneumonectomy
  • Atelectasis
  • Pneumothorax
  • Flail chest- Paradoxical movement
  • an endotracheal tube inserted in right or left mainstem bronchi
41
Q

Eupnea Breathing pattern

A

Normal rate, depth, and rhythm

42
Q

Tachypnea causes

A
  • hypoxia
  • fever
  • pain
  • CNS problem
43
Q

Bradypnea (oligopnea) causes

A
  • sleep
  • drugs
  • alcohol
  • metabolic disorders
44
Q

hyperpnea

A

increased respiratory rate, increased depth, regular rhythm

45
Q

hyperpnea causes

A

metabolic disorders/ CNS disorders

46
Q

Cheyne Stokes breathing

A

Gradually increasing then decreasing rate and depth in a cycle lasting 30-180 seconds, with periods of apnea lasting up to 60 seconds

47
Q

Cheyne Stokes Breathing causes

A
  • increased intracranial pressure
  • brainstem injury
  • drug overdose
48
Q

Biot’s breathing

A

Increased respiratory rate and depth, with regular periods of apnea. Each breath has the same depth

49
Q

Biot’s Breathing Causes

A

CNS problem

50
Q

Kussmaul’s Breathing

A

Increased respiratory rate ( usually over 20 bpm), increased depth, irregular rhythm breathing sounds labored. This can be caused by diabetic ketoacidosis

51
Q

Kussmaul’s Breathing causes

A
  • Hypoxemia
  • metabolic acidosis
  • renal failure
  • diabetic ketoacidosis
52
Q

Apneustic Breathing

A

Prolonged gasping inspiration followed by extremely short, insufficient expiration.

53
Q

Apneustic Breathing causes

A
  • Problem with respiratory center
  • trauma
  • tumor
54
Q

Hypopnea

A

Shallow or slow breathing

55
Q

Accessory muscles of ventilation

A
  • internal intercostal
  • scalene
  • sternocleidomastoid
  • pectoralis major
  • Abdominal muscles( oblique, rectus abdominus)
56
Q

Assessment of airway patency

A
  • tracheal shift/deviation
  • enlarged thyroid
  • short receding mandible
  • enlarged tongue
  • bull neck
  • limited range of motion of the neck or cervical spine
57
Q

mallampati class 1

A
  • soft pallet
  • uvula
  • fauces
  • pillars visable
58
Q

Mallampati Class 2

A
  • soft palate
  • uvula
  • fauces visable
59
Q

Mallimpati Score 3

A
  • Soft Palate
  • base of uvula visable
60
Q

Mallimpati Score 4

A

Hard palate only visible

61
Q

What Mallampati scores are considered difficult airways?

A
  • Class 1 and class 2
  • use fiberoptic bronchoscope or a video-assisted device
62
Q

Assessment by palpation

tachycardia > 100 bpm indicates?

A
  • hypoxemia
  • anxiety
  • stress
  • Recommend oxygen therapy
63
Q

Assessment by palpation

Bradycardia < 60 bpm indicates?

A
  • Heart failure
  • shock
  • code/emergency
  • Recommend Atropine
64
Q

How much change in heart rate shows adverse reaction?

A

> 20bpm

65
Q

paradoxical pulse/pulsus paradoxus

A

pulse/blood pressure varies with respiration

May indicate

  • Severe air trapping
  • status asthmaticus
  • tension pneumothorax
  • cardiac tamponade
66
Q

Tactile fremitus

A

vibrations that are felt by the hand on the chest wall

67
Q

Crepitus

A

Bubbles of air under the skin that can be palpated and indicates the presence of subcutaneous emphysema

68
Q

chest motion symmetry

A

using both hands and placing them on the pts chest, noting the distance the hands move on patient inspiration. If one hand moves more than the other this is asymmetrical chest rise, and could be atelectasis or pneumothorax

69
Q

Percussion sounds

Resonant

A

Normal air-filled lungs, gives a hollow sound

70
Q

Percussion sounds

Flat

A

normally heard over the sternum, muscle, or areas of atelectasis

71
Q

Percussion sounds

Dull

A

Normally heard over fluid-filled organs such as the heart or liver. Pleural effusion or pneumonia will cause this thudding sound

72
Q

Percussion Sounds

Tympanic

A

Normally heard over air-filled stomach, a drum-like sound and indicates increased volume when heard over the lungs

73
Q

Percussion Sounds

Hyperresonant

A

Booming sound that can be heard in an area of the lung where either a pneumothorax or emphysema may be present

74
Q
A
75
Q

Auscultation

Bilateral Vesicular sounds

A

Normal sounds in both lungs

76
Q

Auscultation

Bronchial Breath Sounds

A
  • Normal sounds heard over the trachea or bronchi.
  • these sounds heard over the lung periphery would indicate lung consolidation
77
Q

Auscultation Technique Egophony

A

The patient is instructed to say “e” and it sounds like an “a”. This would indicate consolidation of the lung tissue as with a pneumonia-like condition

78
Q

Broncophony and whispered Pectoriloquy

A

Terms that refer to increased intensity or transmission of the spoken voice and indicate consolidation and pneumonia

79
Q
A

Patient Assessment Kettering (3 decks)

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