POD quiz 5-7 Flashcards
What are the four basic physical assessment techniques/methods used during physical assessment?
Inspection, palpation, auscultation, olfaction
What is the purpose of performing a physiological assessment?
Understand a person’s strengths and weaknesses, identify possible problems with cognition, emotional reactivity, and recommend treatments (address the patient’s needs) (provides valuable information for all members of the patient’s inter professional health care team)
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 the major physiological systems of the body
How would the psychiatric nurse assess a person’s orientation and level of consciousness?
Orientation is determined by the state of awareness so you would ask questions about person, place, time, and situation (what is the month and year, where are you right now, first and last name)
Level of consciousness exists along continuum from fully awake, alert, and cooperative to unresponsive
To assess: talk with the patient, asking questions about events involving the patient or concerns about any health problems
Glasgow scale is used for an objective measurement if lower level of consciousness is detected
What is the Glascow Coma Scale?
Clinical scale used to reliably measure a person’s level of consciousness – assesses a person based on their ability to perform eye movements, speak, and move their body
When would you use the Glascow Coma Scale?
After a head injury, suspected brain bleed, stroke, cranial surgery, and if someone just has a general altered state of consciousness
How would the psychiatric nurse assess a patient’s pupil size and reaction to light?
Assess pupils in a dim room, using a bright pen light
shine the light moving from the lateral across the open eye to the space between the eyes. Note the pupil’s reaction to light (do they constrict when light is shined in eye?)
Use the pen light to determine pupil size based on 1-10mm
Assess pupils are equal, round, reactive to light, and accommodating (PERRLA)
What does the acronym ‘PERRLA’ represent?
Pupils equal, round, reactive to light, and accommodating
How does the psychiatric nurse assess the patient’s motor strength to the extremities?
Assess motor strength to all 4 limbs
through commands-push, pull, wiggle, grip (strong/moderate/weak)
To stimuli: flexion, extension, withdraws, absent
Assess hand grip & foot push/pull and toe wiggle
What does the term drift mean?
Drift is when you ask the patient to hold both arms out straight (like holding pizza box) and ask them to close their eyes. if one arm begins to fall – that is considered drift which could indicate something wrong in the brain or an early indicator of muscle-skeletal weakness
2 common pain assessment scales
LOTTAARP & OPQRSTUV
LOTTAARP
location, onset, timing, type, associated symptoms, alleviating factors, radiating, precipitating
How would you conduct a pain assessment?
through scales, picture visuals, descriptions (self-report), behaviour
What does the acronym ‘OPQRSTUV’ represent in relation to pain assessment?
Onset, palliation (what makes better or worse), quality (what does it feel like), region/radiation (where & does it radiate), severity (rate using validity scoring pain tool), timing (when beginning, how long last), understanding (what do you think is causing it, how is affecting you), value (views/feelings about symptom that important to you/family (culture/religious values))
What is the difference between a self-report pain scale and a behavioral observational pain tool?
self-report pain: numerical, descriptive or visual – can be used if language barrier, children who can point or nonverbal people
Behavioral observational pain tool: nurse needs to assess verbalization, vocal response, facial and body movements, and social interaction (For those who cannot verbalize pain (infants, unconscious, disoriented, confused . . . etc) important to assess behaviours that are indicative of pain; Moaning, crying, inability to settle, poor appetite, negative emotions (anger, fear, anxiety) = cues may be in pain)
What are the components of a neurological assessment?
Level of consciousness, orientation, glasgow coma scale, PERRLA, motor strength, pain
respiratory assessment steps
RESPIRATORY RATE/RHYTHM/EFFORT, COUGH & SPUTUM, CHEST AUSCULTATION, SOB/DYSPNEA, OXYGEN DELIVERY AND SATURATION
What is the sequence for chest auscultation that allows for comparison of left and right lung fields?
Bilateral pattern – start right upper lung, deep breath, move to left upper lung, deep breath, down to left middle lung, deep breath, across to right middle lung, deep breath, down to right lower lung, deep breath, across to left lower lung, deep breath – can listen to the lateral sides as well so bottom of ribs (each side)
What are normal breath sounds?
Normal: differ in character, depending on area. Bronchovesicular & vesicular sounds heard over posterior thorax
Vesicular: soft, breezy, and low-pitched, inspiration 3x longer than expiration
Bronchovesicular: blowing sounds that are medium-pitched & of medium intensity – inspiration and expiration are equal time
Bronchial: loud, high-pitched with hollow quality – expiration longer (3:1 ratio)
What are adventitious breath sounds?
Adventitious: air passing through moisture, mucus, or narrowed airways. also result from alveoli suddenly reinflating or from an inflammation between the pleural linings
crackles
Crackles: most common in dependent lobes (right and left bases). cause: random, sudden reinflation of groups of alveoli; disruptive passage of air through small airways
- fine crackles: high-pitched, short, interrupted crackling sounds heard during end of inspiration (usually not cleared by coughing).
- Medium crackles: lower, more moist sounds heard during middle of inspiration; not cleared by coughing.
- Coarse crackles: bubbly sounds heard during inspiration, not cleared by coughing.
not continuous – caused by excess fluid in the small air sacs (mucosa from asthma or chronic obstructive pulmonary disease (COPD) or fluid related to pulmonary edema)
rhonchi,
Rhonchi: primarily heard over trachea & bronchi; if loud enough, can be heard over most lung fields. Cause: muscular spasm, fluid, or mucus in larger airways, new growth or external pressure causing turbulence
Character: loud, low-pitched, rumbling coarse sounds heard most often during inspiration or expiration; sometimes cleared by coughing
(asthma & viral upper respiratory tract infection)
wheezes
Wheezes: heard all over lung fields. Causes: high-velocity airflow through severely narrowed or obstructed airway (bronchoconstriction)
Character: high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration
(asthma, acute bronchitis, pneumonia)
pleural friction rub
Pleural friction rub: heard over anterior lateral lung field (if patient is sitting upright). Causes: inflamed pleura, parietal pleura rubbing against visceral pleura
Character: has dry, rubbing, or grating quality heard during inspiration or expiration; does not clear with coughing; heard loudest over lower lateral anterior surface
stridor
Stridor: high-pitched, turbulent sound that can happen when a child inhales or exhales – indicates an obstruction or narrowing in upper airway, outside of chest
What would the nurse assess in relation to shortness of breath (dyspnea),
dyspnea: clinical signs: exaggerated respiratory effort, use of accessory muscles, nasal flaring, increased rate and depth of respiration
Assess and record respirations, including rate and depth and auscultate every 4 hours. use a visual analogue scale to help patients make an objective assessment.
What would the nurse assess in relation to a cough
Cough: determine frequency and whether it is productive (sputum) or not
What would the nurse assess in relation to sputum?
Sputum: collect data about the type and quantity of sputum. inspect for colour, consistency, odour, presence of blood and amount
What are the components of a respiratory assessment?
Respiratory rate, rhythm, effort, use of accessory muscles; cough & sputum; chest auscultation; SOB/dyspnea, oxygen delivery system, oxygen saturation
What are the signs and symptoms of hypoxia?
Hypoxia: insufficient oxygenation of tissues
Apprehension, restlessness, inability to concentrate, declining level of consciousness, dizziness, and behavioral changes
What is cyanosis? How does the psychiatric nurse assess cyanosis in a patient?
Cyanosis: low oxygenation of tissues that results in a blue discolouration of the skin and mucus membranes
Central cyanosis: tongue, soft palate, & conjunctiva of eye
Peripheral cyanosis: extremities, nail beds, and earlobes
Administration of oxygen and treatment of underlying cause, such as an obstructed airway
What are three ways deep breathing and coughing facilitates respiratory functioning?
- deep breathing prevents panting or hyperventilation
- deep breathing prevents airway collapse by facilitating maintenance of positive airway pressure
- coughing clears the airway
What are some other nursing interventions that the student psychiatric nurse could implement to improve respiratory functioning?
Orthopneic position: frequently used by patients with respiratory problems, helps expand the chest and lungs to allow more oxygen to enter
Deep breathing and coughing
Elevate head of bed
dysrhythmia
Dysrhythmia: failure of the heart to beat at regular successive intervals and can be life threatening
murmurs
Murmurs: sustained swishing or blowing sounds heard at the beginning, middle, or end of the systolic or diastolic phase. They are due to increased blow flow through a normal valve, forward flow through a stenotic valve or into a dilated vessel or heart chamber, or backward flow through a valve that fails to close
What are the components of a peripheral vascular assessment?
Colour, temperature, capillary refill, edema, and pulses
What are the components of a peripheral neurological assessment?
Pain, sensation, and motor function
What is a neurovascular assessment?
Assessment of the sensory and motor function (neuro) and peripheral circulation (vascular) by checking pain, sensation, motor function, assessment of colour, temperature, capillary refill, edema, and pulses
– early detection of impaired blood flow or damaged nerves is essential in preventing permanent deficits, loss of a limb and even death
What are some indications for a psychiatric nurse to perform a neurovascular assessment on a patient?
Patients with: fractures, cast, orthopedic or spinal injury, signs of infection of limb, circumferential burns, and restrictive dressings
What does the term capillary refill mean?
Reliable method for detecting changing in blood flow – time taken for colour to return to an external capillary bed after pressure is applied to cause blanching
How does the psychiatric nurse assess the patient’s capillary refill?
Apply gentle, firm pressure with the thumb to nail bed and release to observe – the nail bed will appear white, however the pink colour should return immediately on release of pressure (use side of nail if nail polish)
What is meant by the acronym CWMS?
Colour, warmth, movement, sensation
How does the psychiatric nurse assess the patient’s CWMS?
Colour: provide information about perfusion – should be similar colour all over body, visually inspect patient. Warmth: provides information about perfusion, use back of hand to palpate patient, comparing to opposing limb. Movement: provides brief overview about musculoskeletal function – get patient to perform movements. Sensation: asking if client has any numbness/tingling, brief overview of client baseline. Altered sensation may be result of impaired neurological function or impaired perfusion.
What does the psychiatric nurse include in their assessment of peripheral edema?
Whether the edema is pitting vs nonpitting, rating (mild, moderate, severe), and location
What are common peripheral pulse sites used to assess tissue perfusion?
Carotid, brachial, radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis
What are the components of a cardiovascular assessment?
Cardiovascular assessment: blood pressure and heart rate, CWMS (colour, warmth, movement, sensation on all limbs), capillary refill (fingers and toes), and chest discomfort, pressure or pain
What are the components of a neurovascular assessment?
Neurovascular assessment:
Peripheral neurological: pain, sensation, and motor function
Peripheral vascular: colour, temperature, capillary refill, edema, pulses
What assessment techniques would the psychiatric nurse use when assessing the abdomen? What is the correct order for conducting these assessment techniques?
Abdomen inspection (flat/round/distended, bruising/scars/symmetry)
Abdomen auscultation (bowel sounds: active, hypo/hyperactive)
Abdomen palpation (soft/firm/hard, tender/non tender)
Assess for: nausea & vomiting, appetite, dietary or fluid restrictions, continence/incontinence, last bowel movement
Last bowel movement important to determine if they are experiencing constipation, diarrhea – medication, no movement, diet, privacy can cause this
Bristol stool chart: colour, odour, consistency, frequency, shape & constituents (other things in the stool)
WHAT TO NOTE FOR INSPECTION (ABDOMEN)
FLAT, ROUND, DISTENDED, BRUISING, SCARS, SYMMETRY
WHAT TO NOTE FOR AUSCULTATION (ABDOMEN)
BOWEL SOUNDS
WHAT TO NOTE FOR PALPATION (ABDOMEN)
SOFT, FIRM, HARD, TENDER OR NON-TENDER
What is the procedure for assessing bowel sounds?
Divide the abdomen into 4 quadrants, auscultate (5-15 secs) in each quadrant for evidence of gurgling, which suggested peristalsis
hypoactive bowel sounds
Hypoactive bowel sounds: less than 5 per minute due to paralytic ileus after abdominal surgery
absent bowel sounds
no sounds - assess for 5 minutes
hyperactive bowel sounds
more than 35 sounds per minute, loud high-pitched noises or grumbling noise could mean small intestine obstruction or inflammatory infections present
What characteristics does the psychiatric nurse assess in relation to stool?
Colour, odour, consistency, frequency, shaper & constituents
What factors impact the process of bowel elimination?
DIET, FLUID INTAKE, PHYSICAL FUNCTIONING, PERSONAL BOWEL ELIMINATION HABITS, PRIVACY, PSYCHOLOGICAL FACTORS, MEDICATION, AND PATHOLOGICAL CONDITIONS
What are some common bowel elimination problems?
Constipation, diarrhea, fecal incontinence, impaction, hemorrhoids
What nursing interventions can the student nurse implement in relation to bowel elimination problems?
Sitting positions, positioning on the bedpan, diet, no privacy, medication
What characteristics does the psychiatric nurse assess in relation to urine?
Urinary frequency, urgency, dysuria, hesitancy, retention, polyuria, oliguria, nocturia, hematuria, last void, continence/incontinence
incontinence
Incontinence: involuntary loss of urine
urgency
Urgency: sudden and compelling urge to void that cannot be postponed
dysuria
Dysuria: painful or difficult urine
frequency
Frequency: voiding more than 8 times in 24 hours
hesitancy
Hesitancy: difficulty initiating urination
urinary retention
Urinary retention: unable to empty all the urine from your bladder
polyuria
Polyuria: voiding large amounts of urine
oliguria
Oliguria: diminished urinary output relative to intake (usually 400mL/24hr)
nocturia
Nocturia: getting up at night to void one or more times
hematuria
Hematuria: blood in the urine
What factors affect urination?
Medical history, surgical history, environment, medical conditions (infection, trauma), chronic diseases (MS, spinal cord injury, stroke, dementia), bowel elimination pattern – constipation affects, lifestyle and quality of life
HOW TO PROMOTE REGULAR MICTURITION, COMPLETE BLADDER EMPTYING, AND PREVENTION OF INFECTION?
PROPER POSITIONING, GIVE REMINDERS, ENCOURAGE FLUID INTAKE, VOIDING REGULARLY (Q3-4HRS), SOUND OF WATER, STROKE INNER THIGH
What are the components of a gastrointestinal assessment?
Inspection, auscultation, palpation, assess subjective data
What are the components of a genitourinary assessment?
Inspection, frequency, urgency, dysuria, hesitancy, retention, last void, continence/incontinence
INTEGUMENTARY ASSESSMENT STEPS
HEAD-TO-TOE SKIN CHARACTERISTICS FROM SKIN COLOR, TEXTURE, THICKNESS, TURGOR, TEMPERATURE, AND HYDRATION
SKIN INTEGRITY ASSESSMENT STEPS
CHECK FOR INTACT OR NON-INTACT SKIN, AREAS OF PRESSURE SORES, LESIONS/WOUNDS, DRESSINGS OR TUBING
What does the psychiatric nurse assess in relation to the patient’s hair and nails?
Fingers, toes, feet, nails
What skin characteristics does the psychiatric nurse assess?
Colour, texture, thickness, turgor, temperature, hydration
NEUROLOGICAL ASSESSMENT STEPS
CHECK EYES/PUPILS (PERRLA), ORIENTATION AND LEVEL OF CONSCIOUSNESS (GLASGOW COMA SCALE), MOTOR MOVEMENT/STRENGTH/SENSATION, AND LEVEL OF PAIN
WHAT IS ACCOMMODATION?
CONSENSUAL REACTIVITY OF THE EYES, WHERE BOTH EYES DILATE AND CONSTRICT SIMULTANEOUSLY to accommodate the focus on the object
WHAT IS ORIENTATION?
THE UNDERSTANDING OF WHAT IS HAPPENING IN YOUR SURROUNDINGS (PERSON, PLACE, TIME, AND SITUATION)
