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Nursing 130 > Physical Assessment > Flashcards

Physical Assessment Flashcards

1
Q

Why do we assess patients

A

To establish a baseline & help identifying changes in patient condition

Screen for new symptoms and new health problems

Monitor status of previous problems

Prevent potential problems

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2
Q

Different types of assessments

A

Comprehensive
Ongoing partial
Focused
Emergency

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3
Q

Comprehensive assessment

A

Done upon admission of new patient

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4
Q

Ongoing assessment

A

Done at every beginning of shift

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5
Q

Focuses assessment

A

Done only 1 area to assess specific area

Normally area where patient has most complain

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6
Q

Emergency assessment

A

Done to determine life threatening or unstable conditions

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7
Q

What to focus on during assessment

A

Physical responses to illness

Patient’s functional status(how well they can take care of themselves)

Stressors that may be present (emotional/mental/environmental)

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8
Q

How to prepare for physical assessment

A

Ask about pain, how strong they feel at that moment, or if they have anxiety

Explain everything as you go

Explain it’s painless

Build a trusting rapport

Use proper positioning patient and you

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9
Q

Preparing environment

A

Maintain privacy

Lower noise control

Use good lighting

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10
Q

Preparing yourself

A

Know patients situation and diagnosis before

Ask for help if needed

Speak with patient in a comforting way

Bring all equipment needed

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11
Q

Positions used in physical assessment

A 
Standing
Sitting
Supine
Dorsal recumbent
Sims
Prone
Lithotomy 
Knee chest
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12
Q

Types of data collected

A

Subjective

Objective

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13
Q

Subjective data

A

What patient says

Ex. “I feel short of breath”

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14
Q

Objective data

A

What is observed or measured
Signs or symptoms seen by nurse

Ex. Lung sounds, X-ray results, labs,

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15
Q

How to assess symptoms

A

Ask for:

Location(where)
Quality
Quantity
Chronology(how long)
Meaning to patient
Aggravating or alleviating factors( what makes it feel better)
Associated manifestations
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16
Q

OLD CART acronym for symptom assessment

A

Onset
Location
Duration

Characteristics
Aggravating factors
Relieving factors
Treatment

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17
Q

Groups physical assessment is grouped into

A

Perfusion (circulation)

Oxygenation (respiratory)

Neurological

Gastrointestinal

Genitourinary

Mobility (musculoskeletal)

Integumentary

Ears, nose, throat

Pain

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18
Q

What to assess in perfusion(circulation)

A 
Auscultaré heart sounds
Inspect and touch legs/arms for edema
Touch arms/legs for temperature
Inspect capillary refill
Palpate distal pulses(on feet)
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19
Q

Oxygenation(respiratory)

A

Evaluate breathing effort

Inspect overall skin color

Listen to lung and breath sounds

Inspect chest shape

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20
Q

Neurological

A

Evaluate speech
Assess:

level of consciousness
orientation
PERRLA
Gait

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21
Q

PERRLA

A

Pupils equal round and reactive to light and accommodation

22
Q

GI

A

Inspect abdomen for shape:
Flat, scaphoid, or distended

Palpate abdomen for tenderness/distention

Listen to bowel sounds in all 4 quadrants

23
Q

GI structures at in upper right quad

A 
Pylorous
Liver
Duodenum
Right kidney
Right adrenal gland
Head of pancreas
24
Q

Structures in left upper quadrant

A 
Stomach
Spleen
Left kidney 
Left adrenal gland
Splenic fixture of colon
Body of pancreas
25
Structures in right lower quad
``` Cecum Appendix Right ureter of kidney Right ovary & Fallopian tube Right spermatic cord ```
26
Structures in left lower quad
Sigmoid Colin Left ureter of kidney Left ovary & Fallopian tube Left spermatic cord
27
Structures along abdomen midline
Urinary bladder | Urethra
28
Genitourinary
Inspect and gently palpate bladder ``` Assess & ask about: Bladder of renal pain UTI’s Dysuria Constipation Urinary incontinence Hematuria Urinary retention(in males) ``` Assess after Foley removal because must per within 6 hrs
29
Mobility (musculoskeletal)
Palpate extremities for tenderness Evaluate movement and sensation Assess muscle strength and symmetry of it Observe range of motion in joints
30
Integumentary (skin)
Look for skin lesions or wounds | Color
31
Types of skin lesions
Fissures Erosions Ulcers 1 more
32
Ears, nose, throat | I
Check eyes using PERRLA Assess hearing (based on convo & asking of hearing aids) Check mouth for sores, color, dryness) Face
33
Pain Assessment using PQRST
Palliative/provocative factors - what makes it better and worse Quality - describe pain Radiation/region - where is the pain Severity - how does pain compare to other pain or how bad is pain Temporal factors - does intensity change over time
34
Inspection part of assessment and what is usually inspected
Use sight, hearing, and smell to gather data ``` Ex. of what is inspected Skin color Gait Behavior Posture General appearance ```
35
Palpation part of assessment & what palpate is used for
Touching to gather data Begin with light pressure and then go deeper ``` Exx. Edema Moisture Masses Temperature Turgor ```
36
Percussion
Tapping on skin to listen to sound Used by MDs to assess abdomen, underlying structures and lungs
37
Auscultation & what it is used for
Hearing and listening for gathering data Use stethoscope Always place stethoscope on direct skin Used for listening to heart, lung, and bowel sounds
38
What is diaphragm of stethoscope used for
High pitched sounds
39
What is bell of stethoscope used for?
Low pitched sounds
40
Factors important to health history
Biographical data Reason for seeking health care History of present illness Past medical history Family history Functional health- how good they can take care of themselves Psychosocial and lifestyle factors Review of systems - subjective data
41
Components of a preventative health history
Ask of health history Check for risk of depression Functional ability Level of safety Physical examination Patient education & counseling
42
Cultural considerations go keep in mind
Think of patient in regards to family, culture, and community Be knowledgeable and nonjudgmental Beware of health beliefs of their culture
43
Categories in general survey
``` Appearance:behavior Grooming/hygiene Body type/posture Mental status Speech Vital signs Nutritional status ```
44
Appearance/behavior component of general survey
Signs of distress Do they look their age Mood and mental status Visible skin lesions, skin color Speech and correct behavior for their age Symmetrical facial features
45
Grooming/hygiene
Are they dressed appropriately? How good is their hygiene
46
Body type and posture component of general survey
``` Body size Gait Posture Body movements Use of assistive devices Fall risk? ```
47
Mental status component of general survey
Includes level of consciousness and orientation
48
Levels of consciousness
Normal Obtunded(stuporous) - not totally asleep but little response Lethargic - resembling deep sleep, can be aroused but goes back to sleep Coma - state of unawareness and unresponsiveness
49
How to assess orientation
Ask for time, place, person(what their name is or age), & situation (what brought them to the hospital)
50
Levels of orientation
Alert x3
51
Purpose of documentation
To identity actual & potential health problems Make nursing diagnosis & interventions Plan appropriate care Evaluate patients response to treatment Always document right away so MD knows patient status & can prevent or detect early

Nursing 130 (5 decks)

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