Patient Assessment Flashcards

Question

Carotid pulse site

Answer 1

Place fingers just below the angle of the mandible

Answer 2

Over the femoral artery in the groin | Used during angiography procedures

Answer 3

In the groove b/w the biceps and triceps muscles above the elbow at the antecubital fossa

Answer 4

Taken over the instep of the foot

Answer 5

On the inner side of the ankles

Answer 6

Over the temporal artery in front of ear

Answer 7

At the posterior surface of the knee

Answer 8

Over the apex of the heart (heard with stethoscope) | Most accurate for cardiovascular assessment of children and infants

Answer 9

``` Activity Fever Stress Hyperthyroidism Anemia Stimulants Asthma Medications Diet pills Various forms of heart disease Heart medications Fitness programs with aerobic exercise ```

Answer 10

Maybe sign of a problem with the hearts ability to pump as much blood as the body needs Can be a sign of shock or a circulation problem such a as partially blocked vessel or narrowed blood vessel

Answer 11

Vessels feels soft when checking the pulse | A hard blocked vessel suggests hardening of the arteries

Answer 12

Place index and middle finger over pulse site and count beats for a minute

Answer 13

Adults - b/w 60 and 100 beats per minute

Answer 14

Use p for the abbreviation

Answer 15

Exchanges oxygen and carbon dioxide b/w the external environment and the blood circulating in the body

Answer 16

1 inspiration and 1 expiration

Answer 17

Adult - 12 to 20 beats | Infant - 30 to 60 beats

Answer 18

Rate - how many breaths per minute Depth - shallow or deep Quality - supplying the O2 needs of the patient Pattern - rapid or staggered

Answer 19

Cyanosis Apprehension Restlessness Change in level of consciousness

Answer 20

``` Medication Illness or pathologies Exercise Age Emotion ```

Answer 21

Slow breath with fewer than 12 breaths per minute

Answer 22

Difficulty in breathing, shortness of breath, using more than the normal effort to breath, abnormal respiratory rate

Answer 23

An abnormal condition in which for a person to breath deeply or comfortably must sit or stand

Answer 24

Rapid breath in in excess of 20 breaths per minute

Answer 25

The physiological balance b/w heat produced in the body and heat lost to the environment

Answer 26

Fever - a patient whose body temp is elevated above normal limits

Answer 27

A patient whose body temp is below normal limits

Answer 28

Environment - slightly hotter in hot environments Time of day - lower in the morning Infection/disease/injury Age - decreases slightly with age Emotional status - increases with stress Menstrual cycle - higher during ovulation Physical activity - slight increase but plateaus Site of measurement - oral vs rectal

Answer 29

36-38 degrees Celsius | 96.8-99.8 degree Fahrenheit

Answer 30

Not always appropriate Depends on patient and conditions (infants vs adults) Takes 1-2 minutes

Answer 31

Patient perferred but it's slower and less accurate Safest method Takes 1-2 mins Non-invasive Commonly used for infants Electronic or disposable or glass thermometer with blunt tip maybe used

Answer 32

Accurate (most reliable) and faster but has patient contraindications Use thermometer with blunt tip Least perferred method by the patient Takes 1-2 minutes

Answer 33

Common for children and confused patients | Takes 2-3 seconds

Answer 34

``` Oral - 0 Axillary - A Tympanic -T Rectal - R It is important to include the time in which the temp was taken on the chart ```

Answer 35

Digital/electric - used to take oral, axillary, and rectal Tympanic Temporal artery Disposable - used for children, ICU and isolation patients

Answer 36

Patient history must support the exam requested Avoids the incorrect exam being taken Minimize the amount of radiation the patient recieves Efficiently uses the equipment contrast ect.. Involved in the exam

Answer 37

General term used to describe a failure or circulation in which blood pressure is inadequate to support oxygen perfusion of vital tissues and unable to remove the by products of metabolism Potentially fatal condition

Answer 38

``` Hypovolemic Septic Neurogenic Cardiogenic Allergic or anaphylactic ```

Answer 39

Occurs when a large amount of blood or plasma has been lost, leaving an insufficient amount of fluid in the circulatory system - external hemorrhage - lacerations - plasma loss from burns - internal bleeding from trauma or perforated gastric ulcer - severe dehydration, vomiting, diarrhea, or extreme diuresis

Answer 40

Fluid replacement for low volume shock (saline or blood) Administration of oxygen Medication to promote vasoconstriction

Answer 41

Massive infection occurs in the body Gram negative bacteria is the most common causative organisms to cause septic shock Gram positive bacteria and viruses can be the cause, the body begins immune response by releasing chemicals that increase capillary permeability and vasodilation Has a first phase and second phase

Answer 42

Hot, dry, flushed skin Increase in heart rate and respiratory rate Fever but possibly not in the elderly patient Nausea, vomiting, and diarrhea Normal to excessive urine output Possible confusion

Answer 43

``` Cool, pale skin Normal temperature Drop in BP Rapid heart rate and respiratory rate Anuria Seizures and organ failure ```

Answer 44

Failure of arterial resistance, causing a pooling of blood in peripheral vessels Injury to the nervous system and reaction to meds can cause this Pt's with head and spinal injuries are the most common with this type of shock

Answer 45

Warm, dry skin Bradycardia Hypotension Diminishing peripheral pulses, cool extremities *monitor pulse, respiration and BP every 5 min. With head/spinal injuries monitor BP more closely looking for changes*

Answer 46

Results from cardiac failure of heart to pump an adequate amount of blood to the vital organs The onset may occur over a period of it may be sudden Most vulnerable pt's include those w/ myocardial infarction, dysrhythmias or other cardiac pathologies

Answer 47

``` Complaint of chest pain that may radiate to jaws and arms Dizziness and respiratory distress Cyanosis Restlessness and anxiety Rapid change in LOC Pulse that may be irregular and slow; may have tachycardia and tachypnea Decreasing BP Decreasing urinary output Cool, clammy skin ```

Answer 48

Usually the more abrupt the onset of anaphylaxis the more severe the reaction will be (large bolus injection of contrast media) Anaphylactic shock is the result of an exaggerated hypersensitivity reaction. Occurs when histamine and bradykinin are released causing widespread vasodilation which results in peripheral pooling of blood accompanied by contraction of nonvascular smooth muscles, particularly the smooth muscles of the respiratory tract

Answer 49

``` Itchy skin Urticaria Nasal congestion, watery eyes, sneezing Coughing with possible laryngeal swelling Peripheral tingling Tachycardia or bradycardia Hypotension Feeling of fullness or tightness of chest, mouth, or throat Feeling of anxiety or nervousness ```

Answer 50

``` Abrupt onset of symptoms Bradycardia (<50beats/min) Hypotension (decreases in BP) Severe dyspnea Cardiac arrhythmias Laryngeal swelling Possible convulsions/seizures Loss of consciousness Respiratory arrest or cardiac arrest ```

Answer 51

Do not leave pt alone Stop any infusion and maintain the IV line Notify rad or ER dr Call code team if symptoms are severe Place pt in semi fowler or sitting positions to facilitate respiration Monitor pulse, BP, respiration every 5 min till code team arrives Prepare O2 and intravenous fluids and drug box Always keep track of the time and sequence of events for documentation

Answer 52

Avoid sudden changes in temp - keep pt warm Reduce pain and stress - handle pt gently and with care Reduce anxiety - work in calm, confident manner, reassure the pt and listen to their concerns and answer questions

Answer 53

Stop procedure and assist the pt Elevate feet to increase blood flow to brain Obtain help. If in doubt call a code Check BP and assist the dyspenic pt with O2 Be ready to assist code team and document events

Answer 54

Skin colour Skin temperature Breathing LOC

Answer 55

Easiest way to recognize change Look for cyanosis (bluish colour in the skin) Caused by lack of O2 in the tissues Easily seen on mucous membranes such as lips and lining of mouth If pt look pale and anxious and states they do not not feel well, tech should not leave the pt

Answer 56

Contact thought touch also allows ongoing physical observation Actually ill pt who is in pain will likely be pale, cool and diaphoretic Hot dry skin may indicate fever while moist skin may only be a response to the environment

Answer 57

Changes may be signal onset of serious distress Normal breathing is quiet and calm Abnormal breathing is audible, wheezing, gasping or coughing Sudden onset of rapid, shallow breathing is usually first sign of respiratory distress

Answer 58

Is noted to be establish as the pt's baseline - alert and responsive - drowsy but responsive - unconscious but reactive to painful stimuli - comatose

Answer 59

- they can't be relied upon to remember instructions | - they aren't responsible for their actions or answers

Answer 60

Used to assess LOC and reaction to stimuli in a neurologically impaired pt based on performance - eye opening = score of 1-4 - verbal response = score 1-5 - motor response = score 1-6 The highest possible score is 15, lower scores predict poorer outcomes

Answer 61

Increase in intracranial pressure (ICP) | The is change can be life threatening and physician must be notified immediately

Answer 62

Pt become irritable Pt becomes lethargic Pt's pulse slows down and their rate of respiration decreases

Answer 63

``` Temp Humidity Lighting Ventilation Colour of surroundings Noise ```