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
