Health Assessment Basics

Question 1

Where do the health assessments take place?

Answer 1

The SIM centre

Question 2

What do you cover in your health assessment?

Answer 2

Professional Behaviour, Documentation, Vital signs, and 1/4 physical assessments.

Question 3

What is generally involved in a neurological assessment?

Answer 3

Coordination, balance, reflexes, sensation and vibration.

Question 4

What is generally involved in a Cardiovascular assessment?

Answer 4

Apical pulse and peripheral vascular circulation.

Question 5

What is generally involved in a Special senses assessment?

Answer 5

Vision and hearing.

Question 6

What is generally involved in a Respiratory assessment?

Answer 6

Posterior chest assessment.

Question 7

How do you correctly rectify errors/mistakes in documentation?

Answer 7

Straight line to cross out with your initials next to it and also the word ‘error’.

Question 8

What are the two first things you do on entering the room for an osce?

Answer 8

Introduce self and what you are doing and preform hand hygiene.

Question 9

If the patient needs to reveal skin or remove clothing what do you offer?

Answer 9

Privacy.

Question 10

What is an imortant thing you need to do before taking notes?

Answer 10

Ask for consent and explain reason for taking notes.

Question 11

Why do we take notes in nursing?

Answer 11

Measuring and recording a patient’s vital signs accurately is important as this gives an indication of the patient’s physiological state. Aka they help us to identify any physical deterioration or improvement.

Question 12

What is important to do with the patient when having a discussion?

Answer 12

Use IR skills especially active listening.

Question 13

Before preforming vital signs what steps do you need to take?

Answer 13

Explain the procedure to the client, gain consent, preform hand hygiene, and gather equipment.

Question 14

When should you be preforming hand hygiene?

Answer 14

Before touching a patient, Before a procedure, After body fluid/exposure risk, After touching a patient, and After touching patient surroundings.

Question 15

When should you preform hand hygiene from when you enter the room and to after you take the patients vitals?

Answer 15

Wash your hand first when you enter the room, Before beginning the vitals, after completing vitals and then before taking blood pressure then after taking blood pressure.

Question 16

What are the steps for taking temperature?

Answer 16

1. Correctly position the patients ear an inspect for occlusion. 2. Place protective cover on tympanic probe. 3. Correctly insert the probe and leave in place until it has signalled a result. 4. Remove and read. 5. Dispose of cover and record.

Question 17

What is a tympanic probe?

Answer 17

A less intrusive way to accurately measure body temperature. By measuring body temperature from the tympanic membrane — through the ear canal — the patient will experience maximum comfort.

Question 18

What does it mean when we say we are looking for occlusion?

Answer 18

Looking for an object that fills the outer portion of a person’s ear canal.

Question 19

What is the order in which we take vital signs?

Answer 19

Temperature, Radial pulse, Respirations, Pulse oximetry, and Blood Pressure.

Question 20

What equipment do we need to set up before taking vital signs?

Answer 20

Tympanic probe, fob watch, pulse oximetry sensor, stethoscope, and blood pressure cuff. Also consider hand sanitiser and table/pillow.

Question 21

What are the steps in which you take the radial pulse and respiratory rate?

Answer 21

1. Have the patient in a comfortable position 2. Apply finger pads to radial pulse and locate. 3. Count this for 30seconds then x2 4. For the following 60 seconds visually count respiration rate 5. Note findings on sheet ensuring correct values.

Question 22

How would you explain what you are going to be doing as a part of taking vital signs?

Answer 22

Taking your vital signs includes using a tympanic probe to take your temperature just at the entrance of your ear canal, taking your radial pulse on your wrist and visually noting your respiration rate, this will also include using a pulse oximeter on a finger and then finally applying a blood pressure cuff to your upper arm. Does this sound okay with you?

Question 23

What range do you need to obtain the accurate radial pulse and respiratory rate in?

Answer 23

Pulse within 4, and Respirations within 2

Question 24

What are the steps of taking pulse oximetry?

Answer 24

Step 1. Complete a circulatory check (capillary refill). Step 2. Attach correctly. 3. Instruct the patient to breathe normally, relax, and minimise movement. 4. Read and record.

Question 25

What do you need to do after you have recorded temperature, radial pulse, respiration rate, and pulse oximetry findings?

Answer 25

Ask the patient if they wish to know their findings make sure you compare the findings with the “Normal range in a resting adult”

Question 26

A value that is similar to that of a normal finding in a resting adult can be described as what?

Answer 26

An expected finding.

Question 27

What is the expected temperature for a resting adult?

Answer 27

Between 37.9 celsius and 36.0 celsius.

Question 28

What is the expected radial pulse rate for a resting adult?

Answer 28

Expected findings are between 50bpm and 89bpm

Question 29

What is the expected respiration rate for a resting adult?

Answer 29

12-20 breaths/min

Question 30

What is the expected pulse oximetry reading for a resting adult?

Answer 30

96 and above in expected findings.

Question 31

What does pulse oximetry mean?

Answer 31

Pulse oximetry is a noninvasive method for monitoring a person’s oxygen saturation.

Question 32

Why do we measure a patients oxygen saturation?

Answer 32

The purpose of pulse oximetry is to check how well your heart is pumping oxygen through your body.

Question 33

Why do we measure respiration rate as nurses?

Answer 33

Respiratory rate (RR), or the number of breaths per minute, is a clinical sign that represents ventilation (the movement of air in and out of the lungs). A change in RR is often the first sign of deterioration as the body attempts to maintain oxygen delivery to the tissues.

Question 34

Where would you find the radial pulse?

Answer 34

Your radial pulse can be taken on either wrist. Use the tip of the index and third fingers of your other hand to feel the pulse in your radial artery between your wrist bone and the tendon on the thumb side of your wrist.

Question 35

Before taking temperature what should you check of on the vital signs sheet?

Answer 35

The loc (Level of consciousness), once the patient has responded you should check ‘alert’.

Question 36

How do you accurately document respiratory rate?

Answer 36

Document actual numerical value.

Question 37

How do you accurately document temperature?

Answer 37

Document value with an ‘X’

Question 38

How do you accurately document Heart Rate?

Answer 38

Document value with an ‘X’

Question 39

How do you accurately document Oxygen saturation?

Answer 39

Document actual numerical value.

Question 40

How do you accurately document blood pressure?

Answer 40

Document systolic with an ‘X’

Question 41

How do you accurately document Oxygen?

Answer 41

Tick room air for the BN assessment.

Question 42

Before taking blood pressure what do you need to say?

Answer 42

Consent and explain procedure. Aka “Am I still okay to apply this blood pressure cuff to your arm, (hopefully they say yes) I will just tighten that and use my stethoscope to listen and record the values”

Question 43

What are the steps of measuring blood pressure?

Answer 43

1. Explain procedure and gain consent. 2. Gather the equipment. 3. CLEAN earpieces on stethoscope. 4. Put arm at heart level and locate brachial pulse. 5. Position the blood pressure cuff above the antecubital fossa, centre tubing over the brachial pulse. 6. Palpate pulse 7. Preform assessment. make sure you deflate 2mmhg/sec 8. Ask the student if they wish to know response. 9. leave client in comfortable position and compare findings.

Question 44

What is the brachial pulse?

Answer 44

Pulse that which is felt over the brachial artery at the inner aspect of the elbow; palpated before taking blood pressure to determine location for the stethoscope.

Question 45

What is the antecubital fossa?

Answer 45

a triangular-shaped depression, located between the forearm and the arm on the anterior surface of the elbow, with the apex of the triangle pointing distally.

Question 46

Define systolic

Answer 46

Relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries. Blood pumps oxygen to body.

Question 47

Define diastolic

Answer 47

Relating to the phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood. Deoxygenated blood fills back into heart.

Question 48

Why do we measure the systolic blood pressure?

Answer 48

The pressure inside of the artery when the heart is contracting to pump blood.

Question 49

Why do we measure the diastolic blood pressure?

Answer 49

The diastolic pressure is the pressure inside the artery once the heart is resting between beats.

Question 50

What important terms will you need to remember when doing the blood pressure assessment?

Answer 50

Systolic, Diastolic, Brachial pulse, antecubital fossa, sphygmomanometer, korotkoff, and palpate.

Question 51

What is the name for a blood pressure cuff?

Answer 51

Sphygmomanometer.

Question 52

What is a korotkoff sound?

Answer 52

Korotkoff sounds are generated when a blood pressure cuff changes the flow of blood through the artery.