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CP PNUR 2130 POD Quizzes > POD #2 Unit 5 - 7 > Flashcards

POD #2 Unit 5 - 7 Flashcards

1
Q

What are the four basic physical assessment techniques/methods used during physical assessment?

A

Inspection (observe coughing etc)

Palpation (feeling)

Auscultation (listening)

Olfaction (smelling)

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2
Q

What is the purpose of performing a physiological assessment? When does the psychiatric nurse perform a physiological assessment?

A

Performed at the beginning of each shift to establish a baseline and detect abnormal findings in major physiological systems of the body

Completed in a systematic manner (starting from head of the patient and working towards the toe)

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3
Q

How would the psychiatric nurse assess a person’s orientation and level of consciousness?

A

Exists on a continuum from full awake and alert to unresponsive

State of awareness

Ask questions about person (full name), place (location), time (month/year), and situation (why are you here)

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4
Q

What is the Glascow Coma Scale? When would you use the Glascow Coma Scale?

A

Assess patients neuro status overtime

Allows for evaluation of a patients neurological status overtime

The higher he score, the better the patients neurological function

“Best” response

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5
Q

How would the psychiatric nurse assess a patient’s pupil size and reaction to light?

A

PERRLA - Pupils equal, round, reactive to light and accommodation (in different distance, lighting)

Assess pupil size in mm

Assess pupils in dim room, using a bright pen light

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6
Q

What does the acronym ‘PERRLA’ represent?

A

Pupils

Equal

Round

Reactive

Light

And Accommodation

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7
Q

How does the psychiatric nurse assess the patient’s motor strength to the extremities?

A

Assess limb movement & strength to all extremities via command or stimuli

To command: strong, moderate, or weak

To stimuli: flexion, extension, withdraws, absent

Assess hand grip and foot push/pull and toe wiggle

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8
Q

What does the term drift mean?

A

Drift: both arms extended (pizza box) whilst eyes closed, assess pronation of arms for early motor deterioration

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9
Q

What are the components of a neurological assessment?

A

Level of consciousness

Orientation

Glasgow coma scale

PERRLA

Motor strength

Pain

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10
Q

What is the sequence for chest auscultation that allows for comparison of left and right lung fields?

A

Start from top to bottom, left to right. Perform sides simultaneously to compare sides (snake pattern)

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11
Q

What are adventitious breath sounds?

A

abnormal breathing

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12
Q

What do the following terms mean: crackles, rhonchi, wheezes, pleural friction rub, and stridor?

A

Adventitious breath sounds heard upon auscultation:

Crackles (fluid build up)
Rhonchi (gurgling/bubble sounds, asthma)
Wheeze (Tubes in lung are tight, COPD)
Pleural Friction Rub (creaky, inflamed pleural surfaces rubbing against each other)
Stridor (high pitched, narrowed upper airways)

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13
Q

What would the nurse assess in relation to shortness of breath (dyspnea)

A

Exaggerated respiratory effort, use of accessory muscles of respiration, nasal flaring, increased rate and depth

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14
Q

What would the nurse assess in relation to a cough

A

Sudden, audible, frequency, productive vs non productive

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15
Q

What would the nurse assess in relation to sputum

A

Color, consistency, odor, blood present

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16
Q

What are the components of a respiratory assessment

A

Respiratory rate, rhythm, effort, use of accessory muscles

Cough and sputum

Chest auscultation

SOB/Dyspnea

Oxygen delivery system

Oxygen saturation

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17
Q

What are the signs and symptoms of hypoxia?

A

insufficient oxygen of tissues (comes before cyanosis) confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin

18
Q

What is cyanosis? How does the psychiatric nurse assess cyanosis in a patient?

A

Cyanosis: low oxygenation of the tissues, resulting in blue discoloration of the skin and mucous membranes

Central: tongue, soft palate, conjunctiva of eye

Peripheral: extremities, nails, fingers

19
Q

What are some other nursing interventions that the student psychiatric nurse could implement to improve respiratory functioning?

A

Position change

Encourage deep breathing and coughing

Orthopneic position

Fowlers position

20
Q

Define Dysrhythmia

A

abnormal heart rhythm

21
Q

Define heart Murmurs

A

sounds made by rapid blood flow to heart

22
Q

What is a neurovascular assessment?

A

Assessment of the sensory and motor function (neuro) and peripheral circulation (vascular)

23
Q

What are some indications for a psychiatric nurse to perform a neurovascular assessment on a patient?

A

Fracture, cast, orthopedic or spinal surgery, signs of infection of limb, circumferential burns, and restrictive dressings

Early detection of impaired blood flow or damaged nerves is essential in preventing permanent deficits, loss of a limb and even death

24
Q

What does the term capillary refill mean?

A

Assess perfusion to extremities

25
Q

How does the psychiatric nurse assess the patient’s capillary refill?

A

Apply pressure on nail bed (blanche), release, assess perfusion (less than 3 seconds)

***(Greater than 3 is delayed and indicates impaired circulation)

26
Q

What is meant by the acronym CWMS?

A

Color, Warmth, Movement and Sensation for all 4 limbs

-> Blood flow to hands and feet

27
Q

How does the psychiatric nurse assess the patient’s CWMS?

A

Ask patient to move fingers, touch and ask if patient can feel your touch

Ensuring colour is appropriate for patient’s skin tone

Palpate hands for warmth (compare consensually) -> cold, cool, warm or hot

28
Q

What does the psychiatric nurse include in their assessment of peripheral edema?

A

Swelling in arms, hands, and feet

Does the area pit? Apply pressure on suspected edema site, and view indents (occasionally non-visible so touch – mild, moderate, or severe)

29
Q

What are common peripheral pulse sites used to assess tissue perfusion? (9)

A

(consensual), are they regular in strength (weak, absent, strong, or bounding) (rhythm? Regular or irregular)

Radial artery (thumb side)

Ulnar (pinky side)

Apical (chest)

Dorsalis pedis (top of foot)

Posterior tibial(inner ankle)

Brachial (bicep)

Femoral (groin)

Carotid (neck)

Popliteal (behind knee)

All completed right to left

30
Q

What are the components of a cardiovascular assessment?

A
  • CWMS X4 Limbs
  • Presence of Edema
  • Cap Refill
  • Pulse (location, quality, rhythm, regular/irregular)
  • Auscultate heartbeat
31
Q

What are the components of a neurovascular assessment?

A

“Fancy CWSM”, assess around foci (ex. orthopaedic injury site), palpate consensual limbs, and for sensation

32
Q

What assessment techniques would the psychiatric nurse use when assessing the abdomen? What is the correct order for conducting these assessment techniques?

A

Expose abdomen and inspect

Inspect, Auscultate, Palpate

Palpate: Right Lower Quadrant, Right Upper Quadrant, Left Upper Quadrant, Left Lower Quadrant

33
Q

What do the terms hypoactive and hyperactive bowel sounds mean?

A

Hypoactive: less than 5 sounds per minute

Hyperactive: more than 35 sounds per minute

Absent = concerning, listen up to 5 mins

34
Q

What characteristics does the psychiatric nurse assess in relation to stool?

A

Color

Odor

Consistency

Frequency

Shape

Constituents

35
Q

What factors impact the process of bowel elimination?

A

Constipation (Intervene with hydration, movement, privacy, posture and fiber)

Diarrhea

Fecal Incontinence

Impaction

Hemorrhoids

Hospital Setting: medication, nutrition, setting, activity level

36
Q

What characteristics does the psychiatric nurse assess in relation to urine?

A

Color

Amount

Clarity

Odor

Presence of blood

37
Q

What do the following terms mean:
incontinence
urgency
dysuria
frequency
hesitancy
urinary retention
polyuria
oliguria
nocturia
hematuria

A

Incontinence: lack of control over bladder

Urgency: the need to

Dysuria: painful, burning

Frequency: how often

Hesitancy: long time to start

Urinary Retention: urge to pee but cannot

Polyuria: increased urine

Oliguria: decreased urine

Nocturia: increased urine at nighttime

Hematuria: blood in urine (know last time void occurred)

38
Q

What factors affect urination?

A

Dysuria

Urinary Incontinence

Hematuria

Urinary Retention

39
Q

What are the components of a gastrointestinal assessment?

A

Abdomen inspection

auscultation, palpation

bristol stool chart

Nausea/appetite

40
Q

What are the components of a genitourinary assessment?

A

Urinary frequency, urgency, hesistancy

Last void

incontinence/continence

41
Q

What skin characteristics does the psychiatric nurse assess?

A

Skin color

Texture

Thickness

Turgor (pinch test for elasticity)

Temperature

Hydration

BRADEN SCALE – risk for skin breakdown

CP PNUR 2130 POD Quizzes (3 decks)

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