Health Assessment/SBAR - REVISED Flashcards
A nurse tells you a pt is stuporious. What does stuporious mean?
Pt is extremly unresponsive; must be shaken to be aroused
What are adventitous breath sounds?
abnormal sounds
IN ORDER, name the 4 techniques to used during physical assessment (not for abdominal assessment)
- Inspection
- Palpation
- Percussion
- Ascultation
IN ORDER, name the 4 techniques to used during an ABDOMINAL assessment
- Inspection
- Auscultation
- Percussion
- Palpation
^BASED ON BOOK (nLM); eapen said: inspection, asculation, palp, percuss
Which physical assessment technique would you use to assess the density of tissue?
A) Inspection
B) Palpation
C) Percussion
D) Asculation
C) Percussion, helps to assess the density of tissues because the act of tapping the body with the fingertips produces vibrations and sound waves. The characteristics of the sounds that are produced indicate the density of the underlying tissue
What assessment technique is used to sense vibrations and underlying structures?
A) Inspection
B) Palpation
C) Percussion
D) Asculation
B) Palpation, uses the sense of touch to assess various characteristics, including vibrations within the body and the shape of underlying structures.
What part of the hand is used to assess surface temperature?
Back of hand
Different parts of the hands are better at assessing certain characteristics of the body. Organize the characteristics into a category (Hint: Which part of the hand is used to assess certain characteristics?). ANSWERS CAN BE USED MORE THAN ONCE
Category:
- Palmar Surface
- Fingers/Fingerpads
Characteristics:
- Firmness
- Tenderness
- Consistency
- Shape
- Contour
Palmar Surface
- Firmness
- Tenderness
- Shape
Fingers/Fingerpads
- Firness
- Tenderness
- Shape
- Contour
- Consistency
Define this type of health assessment: Comprehensive Assessment
(Define it/When do you perform this assessment? What does it provide?)
- Conducted upon admission to a healthcare facility
- Provides baseline
A ___________ assessment includes a full health history and physical assessment
Comprehensive Assessment (Admission)
Compare a Health History from a Physical Assessment based on the type of data it collects
- Health history: collection of subjective data
- Physical assessment: collection of objective data
Define this type of health assessment: Ongoing/Partial/Follow Up Assessment
(Define it/When do you perform this assessment? What does it provide?)
- Conducted at regular intervals during your shift
- Concetrates on identified health problems to monitor for positive or negative changes and evaluate effectiveness of interventions
Define this type of health assessment: Focused Assessment
(Define it/Why its conducted; Provide an example)
- Conducted to assess a specific problem (usually involves focus on 1-2 body systems)
- Ex: Chest pain -» do EKG
Define this type of health assessment: Emergency (Triage) Assessment
(Define it/Why is it conducted)
- conducted in life-threatening or unstable situations
Which equipment used during physical examination visualizes interior eye structures?
Ophthalmoscope
Which equipment used during physical examination examines external ear canal and tympanic membrane?
Otoscope
Which equipment used during physical examination screens for distant vision?
Snellen Chart
Which equipment used during physical examination visualizes lower and middle turbinates of the nose?
Nasal Speculum
Which equipment used during physical examination examines vaginal canal and cervix?
Vaginal Speculum
Which equipment used during physical examination tests auditory function and vibratory perception?
Tuning Fork
Which equipment used during physical examination tests deep tendon reflexes and determines tissue density?
Percussion Hammer
Compare subjective vs objective data
Subjective data: What the pt says/feels
Objective data: Measurable/observable
For each statement below, determine whether the data presented is subjective or objective:
- The nurse observes that the patient is shivering and has goosebumps.
- “I have a headache that won’t go away.”
- The nurse measures the patient’s blood pressure as 130/85 mmHg.
- The patient’s temperature is 100.4°F (38°C).
- The nurse documents that the patient’s respiratory rate is 24 breaths per minute.
- Pt reports pain 8/10 on left leg.
- “I feel nauseous and lightheaded.”
- The nurse notes that the patient’s skin is pale and cool to the touch.
- Female, age 22, smoker for 5+ years.
- Pt family states, “She hasn’t had an appetite all day.”
Subjective Data
- “I feel nauseous and lightheaded.”
- Female, age 22, smoker for 5+ years
- Pt reports pain 8/10 on left leg
- Pt family states “ She hasn’t had an appetite all day.”
- “I have a headache that won’t go away.”
Objective Data
- The patient’s temperature is 100.4°F (38°C).
- The nurse observes that the patient is shivering and has goosebumps
- The nurse measures the patient’s blood pressure as 130/85 mmHg
- The nurse notes that the patient’s skin is pale and cool to the touch
- The nurse documents that the patient’s respiratory rate is 24 breaths per minute.
A nurse is conducting a comprehensive patient assessment. Which of the following are key purposes for perforing a health assessment? (Select all that apply)
A. Identify actual and potential health problems
B. Establish a baseline
C. Identify changes in status
D. Collect, validate, and analyze subjective and objective data to determine the patient’s health status
E. Ignore minor patient complaints
F Identify patient strengths
G: Only documenting the patient’s current complaints
A. Identify actual and potential health problems
B. Establish a baseline
C. Identify changes in status
D. Collect, validate, and analyze subjective and objective data to determine the patient’s health status
F Identify patient strengths
Who can the RN delegate tasks to?
DO NOT DELEGATE WHAT YOU CAN TAPE
- Teach
- Assess
- Plan
- Evaluate
Still working on this maybe,, lol
What are the two components of a health assessment?
- Health History
- Physical Assessment
Biographical data includes _______ and ________ components
- demographics
- psychosocial
What are the two approaches you can take during a physical assessment? What is the difference between the two?
- Head-to-toe approach: systematic assessment addressing ALL systems (head -> toes)
- Systems approach: systematic assessment assessing a body system individually
A nurse is preparing the environment for a physical assessment. Which of the following are appropriate steps to ensure a proper assessment? (Select all that apply)
A. Perform the assessment at the end of the shift when time allows.
B. Gather appropriate supplies.
C. Ensure the room has adequate lighting.
D. Conduct the assessment in a quiet environment (e.g., turn the TV down).
E. Perform the assessment immediately without allowing the patient to empty their bladder.
F. Maintain cultural sensitivity.
G. Position the bed at an appropriate height.
H. Explain that the physical assessment will not be painful.
I. Answer the patient’s questions directly and honestly.
J. Be sure the patient is free from pain before beginning.
K. Provide privacy.
L. Avoid explaining the assessment process to save time.
M. Complete the assessment in the hallway for efficiency.
N. Ensure the assessment is timely (within the first hour of the shift).
Correct Answers: B, C, D, F, G, H, I, J, K, N
Incorrect Answers: A, E, L, M
There are 4 phases of an interview when taking a health history. Name these 4 phases in chronological order.
- Preparatory
- Introduction
- Working
- Termination
There are 4 phases of an interview when taking a health history. Organize the following characteristics into their appropriate stage in which they are performed.
Stages:
- Preparatory
- Introduction
- Working
- Termination
Characteristics:
- Avoid interrupting
- What else? - allows pt to address anything critical/missed
- Quiet environment
- Explore history of present concern/illness (explore sxs)
- Sit at eye level with patient (elevate pt HOB 45°)
- Summarize important concerns
- Explain care routines
- Explain where data is being recorded and stored
- Private setting
- Review current/past records
- Open ended questtions
- Offer yourself as a resrouce
Preparatory
- Quiet environment
- Private setting
- Review current/past records
Introduction
- Sit at eye level with patient (45° of bed)
Working
- Open ended questtions
- Explore history of present concern/illness (explore sxs)
- Avoid interrupting
Termination
- Summarize important concerns
- What else? - allows pt to address anything critical/missed
- Offer yourself as a resrouce
- Explain care routines
- Explain where data is being recorded and stored
What does PPTE stand for?
Person, Place, Time, Event
You will assess the integumentary system by _______ and ________
inspection and palpation
What is the Braden Scale used for? A total score of what number (or less) represent a high risk?
- used to predict pressure ulcer risk
- total score of 12 or less represents a HIGH risk
A nurse assess a patient using the Braden Scale and assigns them a total score of 8. Based on this score, what would be the most appropriate intervention?
A. Reassess the patient in 2 hours and document findings.
B. Implement aggressive pressure injury prevention measures, such as frequent repositioning, pressure-relieving surfaces, and skin protection.
C. Encourage the patient to ambulate independently every 2 hours.
D. Place the patient on an air mattress, including a fitted sheet and chuck for extra cushion on their sacrum
B. Implement aggressive pressure injury prevention measures, such as frequent repositioning, pressure-relieving surfaces, and skin protection.
A nurse assess a patient using the Braden Scale and assigns them a total score of 8. The nurse places the patient on an air mattress that includes a fitted sheet and multiple layers for increase cushioning on the sacral area.
Explain why this is NOT an acceptable.
A total score of 12 or less represents that the pt is at high risk for developing pressure ulcers. To combat this, it is appropriate for the nurse to place the patient on an air mattress; HOWEVERRRRRRR, the nurse can ONLY put ONE LAYER on the mattress (ex: fitted sheet only). Putting layers on the mattress essentially defeats the purpose of it because the layers interfere with the distribution of the weight equally. The air mattress is used to help with the equal distribution of weight to prevent pressure ulcers.
What are the 6 risk factors that you assess when using the Braden Scale?
MF MANS
- Moisture
- Friction and Sheer
- Mobility
- Activity
- Nutrition
- Sensory Perception
Which number ranges on the Braden Scale indicate a Very High Risk, High Risk, Moderate Risk, Low Risk, and No Risk
- Very High Risk: Less than/equal to 9
- High Risk: 10-12
- Moderate: 13-14
- Low Risk: 15-18
- No Risk: 19-23
Describe the following skin problem:
Erythema/Flushing
(What does the pt look like? What type of problem may it indicate?)
What does the pt look like?
- Pt has redness
What type of problem may it indicate?
- Seen in patients with a fever or sunburn
Describe the following skin problem:
Jaundice
(What does the pt look like? What type of problem may it indicate?)
What does the pt look like?
- Pt has yellow discoloration of the skin, eyes, and mucous membranes
What type of problem may it indicate?
- Seen in patients with liver & gallbladder problems
-> ↑ bilirubin levels
Describe the following skin problem:
Pallor
(What does the pt look like? What type of problem may it indicate?)
What does the pt look like?
- Pt has paleness
What type of problem may it indicate?
- Seen in anemic patients
-> ↓ hemoglobin
Describe the following skin problem:
Cyanosis
(What does the pt look like? What type of problem may it indicate?)
What does the pt look like?
- Pt has blue discoloration (typically on lips/fingers)
What type of problem may it indicate?
- Caused by lack of oxygenation/circulation
How do you assess skin turgor?
- Gently pinch the skin (around jugular notch of sternum/clavicle) and see if skin bounces back (2 sec or less is good)
- IF IT STAYS = indicated dehydration/loss of elasticity of skin
-> Increase H2O intake
What is the Glasgow Coma Scale used to assess? Who is it usually used for?
- assess a patients level of conciousness
- typically used to evaluate status of actuely ill patients at risk of acute brain damage
If a patient is labeled at “comatose” what does that mean?
the patient is in a deep coma and cannot be aroused
The maximal score on the Glasgow Coma Scale is ______ and indicated that the patient is ____________________. An overall score of _______ or below is associated with a coma.
- 15
- indicates the patient is fully awake, alert, oriented
- 8
Capillary refill should be no longer than _____ seconds.
3
What does PERRLA stand for?
Pupils Euqal Round Reactive to Light and Accomodate
What does Consensual and Accomodation mean? (in terms of pupils)
- Consensual: BOTH pupils dilate/constrict when light is shined in ONE eye
- Accommodate: pupils change in size when objects are close/further away
Opiods can lead to _________ depression
Respiratory
Barrel chest is when the ______ diameter of the chest is ________, which can be observed in individuals with ______diseases
anteroposterior diameter
increased
chronic lung diseases
The normal chest should be symmetric, with the transverse diameter being ______ than the anteroposterior diameter
greater
T/F: The use of accessory muscles when breathing is normal
False, it is abnormal
Review ascultation points in the front/back for the lungs
Review ascultation points in the front for the heart
Whare are the 3 normal breath sounds and what do they sounds like?
- Bronchial (tubular; louder; wind thru tube)
- Bronchovesciular
- Vesicular (soft, low pitched - wind rustling)
Describe the following abnormal lung sound. What do you hear?In what conditions would you hear these sounds for?
Crackles (Rales)
- Bubbling/Crackling sounds
- Found in patients with Pneumonia, COPD, and fluid in lungs.
Describe the following abnormal lung sound. What do you hear?In what conditions would you hear these sounds for?
Wheezes
- High-pitched, whistling sounds; caused by narrowed airway
- Found in patients with Asthma, COPD, respiratory infection or obstruction in airway
Describe the following abnormal lung sound. What do you hear?In what conditions would you hear these sounds for?
Friction Rub
- Scratchy, grating sound; caused by an inflammed pleura rubbing against chest wall
- Found in patients with Pleurisy, pulmonary embolism, or any condition causing inflammation of the pleura
Describe the following abnormal lung sound. What conditions would you hear these sounds for?
Stridor
Harsh, loud high-pitched noises: caused by narrowing of upper airway
Found in patients with foreign object aspiration, epiglottitis, and anaphylaxis.
Describe the following abnormal lung sound. What conditions would you hear these sounds for?
Rhonchi
- Low-pitched, snoring noises; caused by air passing through or around secretions
- Found in patients with COPD, cystic fibrosis, pneumonia, and chronic bronchitis
Normal sounds of the heart inlude S1 and S2. What do each of these sounds indicate? Which valves are closing?
S1
- ventricular systole
- mitral/tricuspid valves close
S2
- ventricular diastole
- aortic/pulmonia valves close
How would you assess a patient with Deep Vein Thrombosis (DVT)? What signs/symptoms would you observe?
- One leg would appear normal and the other leg would be abnormal
- Pain
- Edema
- Heat
-> Use hand as blade to assess for heat - Redness
What quesitons are important to ask when assessing a patient’s urination?
How often do you pee?
What color is your pee?
Do you feel any pain or burning sensation when you pee?
If a patient has a nindwelling catheter, you are able to directly check the …
amount, color, clarity, sediment, and blood in the urine.
What questions should you ask to gain data about your patient’s poop?
- how often do you poop?
- when was your last bowel movement?
-> ask abt. constipation/diarrhea, consistency and color - do you have hemorrhoids?
- are you passing gas?
Why is it important to ask a patient if they are passing gas if they are recovering from an abdominal surgery?
passing gas is a key indicator that the digestive system is starting to function normally
the diaphgram of the stethoscope is used to hear ___________.
high frequency sounds
the bell of the stethoscope is used to hear __________.
low frequency sounds
Describe the following bowel sounds:
Active
Hyperactive
Hypoactive
Absent
(What are their frequencys? Describe how they sound.)
Active:
- Irregular gurgling every 5-20 seconds
Hyperactive:
- High pitched, loud sounds every 3 seconds
Hypoactive:
- Soft infrequent sounds per minute
Absent:
- No sounds heard after a minute in all quadrants
Where is the point of maximal impulse?
apical; 5th intercostal
(mitral area)
What position is used to take vital signs?
Sitting
What position is used for relaxation of abdominal muscles?
Supine
Which position is used for patients having difficulty maintaining the supine position?
Dorsal recumbent
What position is used for assessment of rectum or vagina?
Sims
What position is used for assessment hip joint and posterior thorax?
Prone
What poition is used to assess of female rectum and vagina; used for brief period only?
Lithotomy
What position is used to assess of the rectal area; used for brief period only
Knee-chest position
What position assesses posture, gait, and balance?
Standing
What does the Glasgow Coma Scale (GCS) measue/assess?
Measures/Assessess:
- Eye opening
- Verbal response
- Motor response
What is assessed during Inspection, Ascultation, Palpation, Percussion
- Inspection - assess size, color, shape, position, & symmetry
- Auscultation - assess sound: pitch, loudness, quality & duration
- Palpation - assess temperature, turgor, texture, moisture, tenderness, & shape
- Percussion - assess location, shape, size, density
