POD #2 Unit 5 - 7 Flashcards
What are the four basic physical assessment techniques/methods used during physical assessment?
Inspection (observe coughing etc)
Palpation (feeling)
Auscultation (listening)
Olfaction (smelling)
What is the purpose of performing a physiological assessment? When does the psychiatric nurse perform a physiological assessment?
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)
How would the psychiatric nurse assess a person’s orientation and level of consciousness?
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)
What is the Glascow Coma Scale? When would you use the Glascow Coma Scale?
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
How would the psychiatric nurse assess a patient’s pupil size and reaction to light?
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
What does the acronym ‘PERRLA’ represent?
Pupils
Equal
Round
Reactive
Light
And Accommodation
How does the psychiatric nurse assess the patient’s motor strength to the extremities?
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
What does the term drift mean?
Drift: both arms extended (pizza box) whilst eyes closed, assess pronation of arms for early motor deterioration
What are the components of a neurological assessment?
Level of consciousness
Orientation
Glasgow coma scale
PERRLA
Motor strength
Pain
What is the sequence for chest auscultation that allows for comparison of left and right lung fields?
Start from top to bottom, left to right. Perform sides simultaneously to compare sides (snake pattern)
What are adventitious breath sounds?
abnormal breathing
What do the following terms mean: crackles, rhonchi, wheezes, pleural friction rub, and stridor?
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)
What would the nurse assess in relation to shortness of breath (dyspnea)
Exaggerated respiratory effort, use of accessory muscles of respiration, nasal flaring, increased rate and depth
What would the nurse assess in relation to a cough
Sudden, audible, frequency, productive vs non productive
What would the nurse assess in relation to sputum
Color, consistency, odor, blood present
What are the components of a respiratory assessment
Respiratory rate, rhythm, effort, use of accessory muscles
Cough and sputum
Chest auscultation
SOB/Dyspnea
Oxygen delivery system
Oxygen saturation
What are the signs and symptoms of hypoxia?
insufficient oxygen of tissues (comes before cyanosis) confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin
What is cyanosis? How does the psychiatric nurse assess cyanosis in a patient?
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
What are some other nursing interventions that the student psychiatric nurse could implement to improve respiratory functioning?
Position change
Encourage deep breathing and coughing
Orthopneic position
Fowlers position
Define Dysrhythmia
abnormal heart rhythm
Define heart Murmurs
sounds made by rapid blood flow to heart
What is a neurovascular assessment?
Assessment of the sensory and motor function (neuro) and peripheral circulation (vascular)
What are some indications for a psychiatric nurse to perform a neurovascular assessment on a patient?
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
What does the term capillary refill mean?
Assess perfusion to extremities
How does the psychiatric nurse assess the patient’s capillary refill?
Apply pressure on nail bed (blanche), release, assess perfusion (less than 3 seconds)
***(Greater than 3 is delayed and indicates impaired circulation)
What is meant by the acronym CWMS?
Color, Warmth, Movement and Sensation for all 4 limbs
-> Blood flow to hands and feet
How does the psychiatric nurse assess the patient’s CWMS?
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
What does the psychiatric nurse include in their assessment of peripheral edema?
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)
What are common peripheral pulse sites used to assess tissue perfusion? (9)
(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
What are the components of a cardiovascular assessment?
- CWMS X4 Limbs
- Presence of Edema
- Cap Refill
- Pulse (location, quality, rhythm, regular/irregular)
- Auscultate heartbeat
What are the components of a neurovascular assessment?
“Fancy CWSM”, assess around foci (ex. orthopaedic injury site), palpate consensual limbs, and for sensation
What assessment techniques would the psychiatric nurse use when assessing the abdomen? What is the correct order for conducting these assessment techniques?
Expose abdomen and inspect
Inspect, Auscultate, Palpate
Palpate: Right Lower Quadrant, Right Upper Quadrant, Left Upper Quadrant, Left Lower Quadrant
What do the terms hypoactive and hyperactive bowel sounds mean?
Hypoactive: less than 5 sounds per minute
Hyperactive: more than 35 sounds per minute
Absent = concerning, listen up to 5 mins
What characteristics does the psychiatric nurse assess in relation to stool?
Color
Odor
Consistency
Frequency
Shape
Constituents
What factors impact the process of bowel elimination?
Constipation (Intervene with hydration, movement, privacy, posture and fiber)
Diarrhea
Fecal Incontinence
Impaction
Hemorrhoids
Hospital Setting: medication, nutrition, setting, activity level
What characteristics does the psychiatric nurse assess in relation to urine?
Color
Amount
Clarity
Odor
Presence of blood
What do the following terms mean:
incontinence
urgency
dysuria
frequency
hesitancy
urinary retention
polyuria
oliguria
nocturia
hematuria
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)
What factors affect urination?
Dysuria
Urinary Incontinence
Hematuria
Urinary Retention
What are the components of a gastrointestinal assessment?
Abdomen inspection
auscultation, palpation
bristol stool chart
Nausea/appetite
What are the components of a genitourinary assessment?
Urinary frequency, urgency, hesistancy
Last void
incontinence/continence
What skin characteristics does the psychiatric nurse assess?
Skin color
Texture
Thickness
Turgor (pinch test for elasticity)
Temperature
Hydration
BRADEN SCALE – risk for skin breakdown
