Patient Assessments

Question 1

What is assessed during the primary assessment?

Answer 1

• Airway (apnea or patency)
• Breathing (WOB and auscultate)
• Check circulation (pulse and rhythm)

Primary = ABCDEs

Question 2

What do you check on the secondary assessment?

Answer 2

Head to toe

• Head, Throat, Thorax, Percussion, Peripheral, legs

Question 3

During the secondary assessment, what should you observe on the Pts head?

Answer 3

• Eyes (PERRLA)
• Nose (nasal flaring, trauma)
• Ears (bleeding, trauma)
• Cyanosis

Question 4

During the secondary assessment, what should you observe on the Pts throat?

Answer 4

• JVD (45 degree angle)
• Tracheal deviation
• Auscultate (will do after intubation to assess cuff leak status)

Question 5

During the secondary assessment, what should you observe on the Pts thorax?

Answer 5

• Auscultate for Brs
• Palpation (edema, pain, SubQ)
• Percussion
• Inspection for trauma/thoracic drainage

Question 6

During the secondary assessment, what should you observe on the Pts peripheral?

Answer 6

Temperature, cap refill, and turgor

Question 7

During the secondary assessment, what should you observe on the Pts legs?

Answer 7

Edema or subq

Question 8

During the secondary assessment, what should you observe on the Pts CxR?

• Soft tissue?

Answer 8

• Patient: check for the right patient
• Position: PA or AP? Is the entire
  chest visible? Proper patient positioning?
• Penetration: Overexposed (radiolucent) or underexposed (radiopaque)
• Lines and tubes: Check for leads, ETT, OG
• Bones – can see 8-10 ribs on inspiration

Question 9

ABG normals?

Answer 9

• pH: 7.35-7.45
• PaC02: 35 -45
• HC03: 22-26
• Sa02: >94%

Question 10

What does a Neurological assessment entail?

Answer 10

Assessing eyes = normal would be equal round, reactive to light

• Abnormal = Dilated and fixed, pinpoint, or dilated

Question 11

Difference between dilated and dilated + fixed eyes?

Answer 11

• Dilated + fixed eyes = brain injury
• Dilated = sympathetic stimulant (cocaine)

Question 12

Normal cap refill?

Answer 12

< 3 seconds

• Increased filling time = Decreased CO

Question 13

What action should be done if JVD is present (before pharmacotherapies and NIV)

Answer 13

Raise the head of bed to 45 degrees

• Deducing venous pressure in the neck veins= decreasing the backflow of blood into the jugular veins.

Question 14

What does pitting edema indicate?

Answer 14

Right heart failure due to poor venous return (or backflow)

Question 15

Signs of possible obstruction?

Answer 15

1. muffled/hot potato voice
2. difficulty swallowing
3. stridor
4. sensation of dyspnea