General Patient Assessment Flashcards
Medication reconciliation
Ensuring a patient’s medication is as accurate and up to date as possible.
Medication Reconciliation time frame
Within 24 hours of admission to hospital
Lethargic,somnolent, sleepy patient
Consider sleep apnea or excessive O2 therapy in a COPD patient
Assessing the emotional state of a pt, what would be seen with anxiety?
watching every movement, respiratory distress, hypoxemia
Assessing emotional state, Panic
Severe hypoxemia, tension pneumothorax, status asthmaticus
6 Activities of daily living
- bathing with a sponge, bath, or shower
- eating
- Dressing
- Toilet Use
- Transferring.
- Urine and bowel continence
Assessing activities of daily living can be used to determine?
- 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
Scoring system used to assess activities of daily living?
Katz scoring system
Measuring subjective symptoms :
orothopnea general malaise dyspnea pain dysphagia
orthopnea
shortness of breathe EXCEPT when in an upright position
general malaise
feeling run-down, nausea, weakness, fatigue, headache, ELECTROLYTE IMBALANCE.
dyspnea
shortness of breath
pain
A reaction of a specific nervous tissue
Dysphagia
difficulty swallowing
Proper interview techniques
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
Assessment by inspection
what you can see, age, height, weight, nourishment, etc
Peripheral edema
presence of excessive fluid in the tissue known as pitting edema
Causes of peripheral edema?
Congestive heart failure Renal failure
Ascites
Accumulation of blood in the abdomen, generally caused by liver failure
Clubbing of fingers
caused by chronic hypoxemia, suggestive of pulmonary disease such as COPD. The thumb and first finger are affected
Venous distension
JVD, (jugular venous distention) Seen during exhalation in patients with obstructive lung disease and air trapping
Capillary refill
Indication of peripheral circulation Color should return in 3 seconds
Diaphoresis
.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 )
Decrease in the color of skin
ashen, pallor
causes of decrease in the color of skin
anemia, acute blood loss, vasoconstriction via reducing blood flow
assessing skin integrity, look for:
pressure sores and ulcers evaluate skin around tracheotomy stoma
assessing chest configuration
straight spine, no leaning forward( kyphosis) or side to side ( scoliosis)
kyphosis
leaning forward spine, convex curvature of the spine
Scoliosis
Spine in S shape, side to side
4 critical life functions, in order of importance in an emergency
- ventilation
- oxygenation
- circulation
- perfusion
Pectus Carinatum
anterior protrusion of the sternum
signs vs symptoms
Signs:
Objective information
- can be measured
- color
- pulse
- edema
- blood pressure ect…
signs vs symptoms
Symptoms :
Subjective information
- things the patient must tell you
- dyspnea
- pain
- nausea
- muscle weakness etc …
Types of advanced directives
- 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
Pectus Excavatum
Depression of part of the entire sternum
Kyphoscoliosis
A combination of scoliosis and kyphosis
Barrell chest
increase in A-P diameter
Symmetrical chest movement
Both sides move equal at the same time
asymmetrical chest movement
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
Eupnea Breathing pattern
Normal rate, depth, and rhythm
Tachypnea causes
- hypoxia
- fever
- pain
- CNS problem
Bradypnea (oligopnea) causes
- sleep
- drugs
- alcohol
- metabolic disorders
hyperpnea
increased respiratory rate, increased depth, regular rhythm
hyperpnea causes
metabolic disorders/ CNS disorders
Cheyne Stokes breathing
Gradually increasing then decreasing rate and depth in a cycle lasting 30-180 seconds, with periods of apnea lasting up to 60 seconds
Cheyne Stokes Breathing causes
- increased intracranial pressure
- brainstem injury
- drug overdose
Biot’s breathing
Increased respiratory rate and depth, with regular periods of apnea. Each breath has the same depth
Biot’s Breathing Causes
CNS problem
Kussmaul’s Breathing
Increased respiratory rate ( usually over 20 bpm), increased depth, irregular rhythm breathing sounds labored. This can be caused by diabetic ketoacidosis
Kussmaul’s Breathing causes
- Hypoxemia
- metabolic acidosis
- renal failure
- diabetic ketoacidosis
Apneustic Breathing
Prolonged gasping inspiration followed by extremely short, insufficient expiration.
Apneustic Breathing causes
- Problem with respiratory center
- trauma
- tumor
Hypopnea
Shallow or slow breathing
Accessory muscles of ventilation
- internal intercostal
- scalene
- sternocleidomastoid
- pectoralis major
- Abdominal muscles( oblique, rectus abdominus)
Assessment of airway patency
- tracheal shift/deviation
- enlarged thyroid
- short receding mandible
- enlarged tongue
- bull neck
- limited range of motion of the neck or cervical spine
mallampati class 1
- soft pallet
- uvula
- fauces
- pillars visable
Mallampati Class 2
- soft palate
- uvula
- fauces visable
Mallimpati Score 3
- Soft Palate
- base of uvula visable
Mallimpati Score 4
Hard palate only visible
What Mallampati scores are considered difficult airways?
- Class 1 and class 2
- use fiberoptic bronchoscope or a video-assisted device
Assessment by palpation
tachycardia > 100 bpm indicates?
- hypoxemia
- anxiety
- stress
- Recommend oxygen therapy
Assessment by palpation
Bradycardia < 60 bpm indicates?
- Heart failure
- shock
- code/emergency
- Recommend Atropine
How much change in heart rate shows adverse reaction?
> 20bpm
paradoxical pulse/pulsus paradoxus
pulse/blood pressure varies with respiration
May indicate
- Severe air trapping
- status asthmaticus
- tension pneumothorax
- cardiac tamponade
Tactile fremitus
vibrations that are felt by the hand on the chest wall
Crepitus
Bubbles of air under the skin that can be palpated and indicates the presence of subcutaneous emphysema
chest motion symmetry
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
Percussion sounds
Resonant
Normal air-filled lungs, gives a hollow sound
Percussion sounds
Flat
normally heard over the sternum, muscle, or areas of atelectasis
Percussion sounds
Dull
Normally heard over fluid-filled organs such as the heart or liver. Pleural effusion or pneumonia will cause this thudding sound
Percussion Sounds
Tympanic
Normally heard over air-filled stomach, a drum-like sound and indicates increased volume when heard over the lungs
Percussion Sounds
Hyperresonant
Booming sound that can be heard in an area of the lung where either a pneumothorax or emphysema may be present
Auscultation
Bilateral Vesicular sounds
Normal sounds in both lungs
Auscultation
Bronchial Breath Sounds
- Normal sounds heard over the trachea or bronchi.
- these sounds heard over the lung periphery would indicate lung consolidation
Auscultation Technique Egophony
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
Broncophony and whispered Pectoriloquy
Terms that refer to increased intensity or transmission of the spoken voice and indicate consolidation and pneumonia
