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Patient Care > Patient Assessment > Flashcards

Patient Assessment Flashcards

1
Q

4 Levels of Consciousness (LOC)

A

Alert and conscious
Drowsy but responsive
Unconscious but reactive to pain stimuli
Comatose

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2
Q 
Define: Orientated 
Lethargic 
Medicated
Stupor
Fainting
A
  • Aware of your surroundings
  • Decreased awareness, low energy, lazy
  • Mentally dulled or altered by drugs
  • Reduced responsiveness
  • Process of losing consciousness
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3
Q

Define:
Semiconscious
Confused
Unconscious

A
  • Knowledge of partial commands and can be woken up
  • Unsure what is happening, disoriented
  • Lack of environmental awareness, non-responsive
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4
Q

What is blood pressure

A

Measuring the forces of the circulating blood on the wall of the arteries

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5
Q

Blood pressure readout

A

Systolic - is a measuring of the pumping action of the heart muscle itself
Diastolic - pressure of the hearts relaxation
Systolic/diastolic

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6
Q

Hypertension

A

High blood pressure

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7
Q

Hypotension

A

Low blood pressure

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8
Q

Uncontrollable factors that affect BP

A

Gender - males have lower BP
Race
Heredity
Age - infants have a higher BP than adults, adolescents have the lowest overall

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9
Q

Controllable factors that affect BP

A 
Exercise 
Nutrition 
Alcohol 
Stress 
Smoking
Body position 
Physical development 
Time of day - lower in the morning than at night 
Health status
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10
Q

How cardiac output affects BP

A

The volume of blood ejected from the left side of the heart in on minute

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11
Q

Peripheral vascular resistance and BP

A

The resistance of flow that must be overcome to push blood through the circulatory system

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12
Q

Blood volume and BP

A

Total amount of circulating blood in the body, normally about 5 litres

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13
Q

Blood viscosity and BP

A

Thickness of blood

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14
Q

Arterial elasticity

A

How flexible the arterial walls are

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15
Q

Blood pressure increases when

A

Cardiac output, peripheral vascular resistance, blood volume and blood viscosity increase
And
Arterial elasticity decreases

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16
Q

Blood pressure decreases when

A

Cardiac output, peripheral vascular resistance, blood volume, blood viscosity decrease
And
Arterial elasticity increases

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17
Q

Normal BP in adults

A

95-120 mm Hg systolic
Over
60-79 mm Hg diastolic

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18
Q

Pre Hypertension BP

A

120 - 139 mm Hg systolic
Over
80 - 89 mm Hg diastolic

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19
Q

Hypertension BP

A

140 - 159 mm Hg systolic
Over
90 - 99 mm Hg diastolic

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20
Q

How many times should BP be taken and what are the considerations

A

3 times a day
Many vary depending on the position of the patients arm and manually taken BP measurements are more accurate than automatic BP machines

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21
Q

What is used to measure BP

A

Syphgmomanometer

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22
Q

What gives you the pulse

A

Contraction of the left ventricle

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23
Q

Factors that affect pulse rate (10)

A

Age - infants have highest, elderly have lowest
Gender - females have higher pulse than males
Emotions - stress, anxiety, excitement, fear increase pulse
Temp - hot climate and fever increase pulse
Posture - standing/sitting require more energy than lying
Activity - exercise increases pulse
Medication - have increase or decrease pulse
Stimulants - coffee/cigarettes increase pulse
Alcohol - decrease pulse
Music - could increase or decrease pulse

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24
Q

Radial pulse site

A

Most accessible and convenient on an adult patient

Over the radial artery at the base of the thumb

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25
Q

Carotid pulse site

A

Place fingers just below the angle of the mandible

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26
Q

Femoral pulse site

A

Over the femoral artery in the groin

Used during angiography procedures

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27
Q

Brachial pulse site

A

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

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28
Q

Dorsalis pedis pulse site

A

Taken over the instep of the foot

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29
Q

Posterior tibial pulse site

A

On the inner side of the ankles

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30
Q

Temporal pulse site

A

Over the temporal artery in front of ear

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31
Q

Popliteal pulse site

A

At the posterior surface of the knee

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32
Q

Apical pulse site

A

Over the apex of the heart (heard with stethoscope)

Most accurate for cardiovascular assessment of children and infants

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33
Q

Conditions that increase resting heart rate

A 
Activity 
Fever
Stress
Hyperthyroidism
Anemia 
Stimulants 
Asthma 
Medications 
Diet pills
Various forms of heart disease
Heart medications
Fitness programs with aerobic exercise
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34
Q

A weak pulse sign

A

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

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35
Q

A weak or absent pulse symptoms

A

Vessels feels soft when checking the pulse

A hard blocked vessel suggests hardening of the arteries

36
Q

How to take a pulse

A

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

37
Q

Average pulse rates

A

Adults - b/w 60 and 100 beats per minute

38
Q

Recording pulse rates

A

Use p for the abbreviation

39
Q

what is Respiration

A

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

40
Q

One full expiration is

A

1 inspiration and 1 expiration

41
Q

Average respiration rates

A

Adult - 12 to 20 beats

Infant - 30 to 60 beats

42
Q

Observing respiration

A

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

43
Q

Respirations fewer than 10/min may result in

A

Cyanosis
Apprehension
Restlessness
Change in level of consciousness

44
Q

Factors that affect respiration

A 
Medication 
Illness or pathologies
Exercise
Age 
Emotion
45
Q

Bradypnea

A

Slow breath with fewer than 12 breaths per minute

46
Q

Dyspnea

A

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

47
Q

Orthopnea

A

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

48
Q

Tachypnea

A

Rapid breath in in excess of 20 breaths per minute

49
Q

Body temperature

A

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

50
Q

Pyrexia

A

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

51
Q

Hypothermia

A

A patient whose body temp is below normal limits

52
Q

Factors that affect body temp

A

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

53
Q

Normal oral temperate range for adults

A

36-38 degrees Celsius

96.8-99.8 degree Fahrenheit

54
Q

Oral temperature

A

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

55
Q

Auxiliary temp site

A

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

56
Q

Rectal temperature site

A

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

57
Q

Tympanic and temporal artery temp site

A

Common for children and confused patients

Takes 2-3 seconds

58
Q

How to chart temperature

A 
Oral - 0 
Axillary - A
Tympanic -T
Rectal - R
It is important to include the time in which the temp was taken on the chart
59
Q

Types of thermometers

A

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

60
Q

Importance of patient info

A

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

61
Q

Definition of Shock

A

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

62
Q

Different types of shock

A 
Hypovolemic 
Septic
Neurogenic
Cardiogenic 
Allergic or anaphylactic
63
Q

What is Hypovolemic shock and is caused by

A

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
64
Q

Treatment for Hypovolemic shock

A

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

65
Q

What is septic shock and the cause of it

A

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

66
Q

Signs and symptoms of first phase of septic shock

A

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

67
Q

Signs and symptoms of second phase of septic shock

A 
Cool, pale skin
Normal temperature
Drop in BP
Rapid heart rate and respiratory rate
Anuria 
Seizures and organ failure
68
Q

What is neurogenic shock and causes of it

A

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

69
Q

Signs and symptoms of neurogenic shock

A

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

70
Q

what is Cardiogenic shock and what causes it

A

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

71
Q

Cardiogenic Shock manifestations

A 
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
72
Q

Allergic or Anaphylactic Shock

A

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

73
Q

Mild to moderate signs/symptoms of allergic reaction

A 
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
74
Q

Serve allergic shock signs/symptoms

A 
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
75
Q

Response to anaphylactic shock

A

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

76
Q

Ways to prevent shock

A

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

77
Q

Tech’s responsibility if the pt is going into shock

A

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

78
Q

Physical Evaluation Includes assessment of

A

Skin colour
Skin temperature
Breathing
LOC

79
Q

Skin Colour Assessment

A

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

80
Q

Skin Temperature Assessment

A

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

81
Q

Breathing Assessment

A

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

82
Q

LOC assessment

A

Is noted to be establish as the pt’s baseline

  • alert and responsive
  • drowsy but responsive
  • unconscious but reactive to painful stimuli
  • comatose
83
Q

When communicating with a pt who is drowsy it is important to remember

A
  • they can’t be relied upon to remember instructions

- they aren’t responsible for their actions or answers

84
Q

Glasgow Coma scale

A

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

85
Q

Changes in the Glasgow coma scale could be caused by

A

Increase in intracranial pressure (ICP)

The is change can be life threatening and physician must be notified immediately

86
Q

Signs of Increased intracranial pressure

A

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

87
Q

Pt physical environment includes

A 
Temp 
Humidity
Lighting 
Ventilation
Colour of surroundings
Noise

Patient Care (11 decks)

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