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The "Fun" class > Skills Exam 3 > Flashcards

Skills Exam 3 Flashcards

1
Q

what is the purpose of a physical examination?

A
  • Gather baseline data
  • compare assessment to other assessments in case of change
  • supplement, confirm, or refute subjective data obtained
  • Identify and confirm nursing diagnosis
  • Make clinical decisions about change in health
  • evaluate the outcomes of care
  • better understand patients educational needs
  • better understand patients physical, mental, and emotional needs
  • Learn the patients culture
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2
Q

When meeting a patient for the first time, it is important to establish a baseline assessment that will enable a nurse to refer back to?

A

A. Physiological outcomes of care
B.The normal range of physical findings
C. a pattern of findings identified when the patient is first assessed
D. clinical judgements made about a patients changing health status

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3
Q
A

C. a pattern of findings identified when the patient is first assessed

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4
Q

what are things that should be done to prepare for an examination?

A
  • Infection control
  • Environment
  • Equipment
  • Physical preparation of patient
  • assessment of age groups
  • Maintain privacy
  • educate and answer any questions before task
  • inform patient what you will be doing before you do it
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5
Q

How should you organize the assessment of each body system?

A

Using a Head to toe approach

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6
Q

what is important to know when doing a head to toe?

A

You should Perform painful procedures at the end

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7
Q

Head to toe tip!

A

compare sides for symmetry

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8
Q

Head to toe tip!

A

offer rest periods as needed

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9
Q

Head to toe tip!

A

Record quick notes during the examination; complete larger notes at the end of the examination

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10
Q

what types of techniques are used during a physical assessment?

A
  • Inspection
  • Auscultation
  • Palpation
  • Percussion
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11
Q

Observation made with eyes, ears, nose as soon as you walk into the room

A

Inspection

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12
Q

what should you watch for during the inspection phase of the assessment?

A
  • Non verbal expressions
  • asses emotional and mental status
  • asses physical movements
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13
Q

During inspection you should….

A

use adequate lighting
use direct lighting to inspect body cavities
-position and expose body parts as needed so all surfaces can be viewed but privacy can be maintained
-validate findings with the patient

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14
Q

Auscultation Requires:

A
  • Good hearing
  • a good stethoscope
  • knowledge
  • concentration and practice
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15
Q

what are sound characteristics to focus on during auscultation?

A
  • Frequency
  • loudness
  • quality
  • duration
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16
Q

Palpation

A

use of touch to gather information

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17
Q

what should be done when performing palpation?

A
  • use different parts of the hands to detect different characteristics
  • hands should be warm and fingernails short
  • you should start with light palpation, end with deep palpation
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18
Q

Percussion

A

Tap the skin with fingertips to vibrate underlying tissues and organs.

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19
Q

what does the sound while doing percussion determine?

A
  • location
  • size
  • density of structures
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20
Q

percussion is usually more performed by…

A

more advanced providers

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21
Q

General Survey

A

General appearance and behavior

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22
Q

Examples of General survey include

A

Gender, race, age, signs of distress, body type, posture, gait, movements, hygiene, dress, mood, speech, signs of abuse, substance abuse

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23
Q

Also included in General survey…..

A
  • Vital signs

- height and weight

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24
Q

what is an assessment done to assess the level of consciousness?

A

AVPU

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25
Q

AVPU

A
  • AWAKE and ALERT
  • Responds to VERBAL stimuli
  • Responds to PAINFUL stimuli
  • UNCONCIOUS
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26
Q

When or why is the Glasgow coma scale used?

A

to asses a patients level of consciousness on a more deeper scale or more detailed scale (usually used in emergency settings and ICU units)

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27
Q

what number of the Glasgow coma scale is a good number meaning patient is responding perfectly

A

15

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28
Q

what number on the Glasgow coma scale means the patient is comatose?

A

<8 remember “less than 8, intubate”

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29
Q

Why is orientation assessed?

A

to determine if the patient is confused

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30
Q

It is good to have a baseline of a patients orientation why?

A

because if their orientation suddenly changes we can know something is wrong and we need to asses

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31
Q

What should you ask to asses orientation?

A
  • Person
  • Place
  • Time
  • Situation
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32
Q

If the patient is acutely confused what should you do?

A

use reality orientation to attempt to reorient them

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33
Q

If the patient is chronically confused( i.e. Dementia), what should you do?

A

you should avoid reorientation it can make the patient become agitated

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34
Q

why do we asses pupils?

A

to determine if the patients neurological response is appropriate

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35
Q

What should you find when assessing the pupils?

A

Both pupils should be the same shape, size and react to light equally

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36
Q

with what disease may the pupils react differently

A

With glaucoma, this would be expected

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37
Q

what should you check when assessing the pupils?

A
  • Size
  • Shape
  • Reactivity to light
  • consensual response
  • accommodation
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38
Q

If all findings are within appropriate limits what do we call it?

A

PERRLA with consensual response present

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39
Q

PERRLA

A

Pupils Equal Round Reactive to Light with Accommodation(and consensual response)

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40
Q

Speech patterns/sounds

A
  • Clear
  • slurred
  • garbled
  • absent(non verbal)
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41
Q

Communication abilities

A
  • Logical

- Illogical

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42
Q

Aphasia

A

the inability to communicate

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43
Q

Forms of aphasia

A
  • Sensory/receptive- patient doesn’t understand the words being spoken to them, they are able to speak may be illogical.
  • Motor/expressive-patient cannot express themselves using verbal communication
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44
Q

Inspecting head and face

A
  • Position, size, shape
  • Symmetrical facial features
  • Because it is common to have a relatively “normal” head size/shape/position and symmetrical facial features, we don’t document it if it is normal
  • if something is outside of expected normal parameters, document it and describe
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45
Q

EENT

A
  • ears
  • eyes
  • nose
  • throat
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46
Q

why do we Asses the ears?

A

to determine if there is any excessive drainage( ex: excessive cerumen)

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47
Q

What question should you ask especially if the patient is having trouble hearing?

A

Do you wear hearing aids?

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48
Q

If patient is hard of hearing you should…

A

speak up loudly and speak in short phrases, then provide appropriate time for the patient to respond

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49
Q

Eyes

A
  • Are eyelids swollen
  • color of sclera
  • Glasses or no glasses( when do they wear them
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50
Q

Nose

A
  • Septum( midline/deviated)
  • Nares( patent/occluded)
  • ask patient if they have any issues breathing through nose or mouth
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51
Q

Lips, oral mucosa, and teeth

A
  • Color should be pink

- lips and oral mucosa should be moist and in tact and teeth should be present, ask if patient wears dentures anyway

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52
Q

Throat (Carotid artery and jugular vein)

A

-Visible pulsations of carotid artery?
-Juglar vein distention present in semi or high fowlers?
Indicate fluid overload

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53
Q

What is the function of the respiratory system?

A
  • Oxygenation

- Gas exchange

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54
Q

Ventilation

A
  • Movement of gases into and out of the lung

- Involves inspiration (inhale) and expiration (exhale)

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55
Q

Diffusion

A

Movement of oxygen and carbon dioxide between alveoli and red blood cells

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56
Q

Perfusion

A

Distribution of red blood cells to and from the pulmonary capillaries

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57
Q

Respirations

A 
-Respiratory rate
(Amount of respirations per minute)
-Ventilatory effort
(Unlabored or labored)
-Ventilatory Pattern
(Pattern of respirations
Even or uneven)
58
Q

If respirations are continuously shallow or deep (usually accompanied by labored breathing), assess patient thoroughly

A
  • Respiratory distress?
  • Just exercised? Winded?
  • Anxiety attack? Hyperventilating?
59
Q

What affects our respirations?

A
  • Current output
  • Exercise
  • Anxiety
  • Age
60
Q

Respiratory assessment: inspection

A

Using your eyes to look at the patient: what do you see? What data can you gather?

  • Rate, pattern, effort
  • Accessory muscle use?
  • Positioning
  • Color of lips, finger tips
  • Is the patient wearing oxygen?
61
Q

Respiratory assessment: Auscultation

A
  • Listen to lung sounds in all five lobes, anteriorly and posteriorly
  • Always listen symmetrically before moving to a different lobe
  • Sit patient in high Fowler’s position
  • Instruct patient to take a deep breath in and out through the mouth, each time you move your stethoscope
62
Q

Respiratory assessment: lung sounds

A

-Clear
-Diminished
-Crackles (Fine
Course)
-Rhonchi
-Wheezes
-Stridor
-Absent

63
Q

If an adventitious sound is auscultated, you must be specific when you document

A
  • Does it occur on inspiration, expiration, or both?
  • Which lobe(s) did you hear it in?
  • Did you attempt to clear it with a cough? Successful?
64
Q

Cough assessment

A
  • is cough present?
  • if yes how frequent is the cough?
  • how long has the cough been present?
  • is there Sputum production?
  • ask patient to cough for you
65
Q

How long should you listen to heart sounds? and what do you listen for?

A

For at least 15 seconds to determine rate and rhythm and loudness of the the heart (strong or distant)

66
Q

what should you do if the arterial pulse rate or rhythm is irregular?

A

assess the apical pulse( pulse found at the apex(bottom) of the heart)

67
Q

What does the abdominal assessment include?

A

gastrointestinal system, genitourinary system, reproductive system (females)

68
Q

Abdominal inspection

A
  • Shape (distended, non distended)

- Also look for: Movements or pulsations, Colostomy, Wounds, bruising, incisions

69
Q

Auscultation of the abdomen

A

Listen for the movement of contents through the bowels (Peristalsis) in a clockwise pattern

70
Q

Bowel sounds: Normoactive

A

Normal sounds consist of clicks and gurgles and occur 5 to 34 per minute

71
Q

Bowel sounds:Hypoactive

A

3 to 5 per minute; seen with decreased bowel motility

72
Q

Bowel sounds:Hyperactive

A
  • Greater than 34 sounds per minute.

- Caused by anxiety, infectious diarrhea, irritation of intestinal mucosa from blood, or gastroenteritis

73
Q

Bowel sounds:Absent

A
  • established only after 5 minutes of continuous listening in one quadrant.
  • Caused by an immobile bowel
74
Q

Palpation of the abdomen

A

should be performed last due to disruption of the bowel, ask the patient before performing if there is any pain present

75
Q

what does palpation detect

A
  • Tenderness
  • distention
  • masses
76
Q

Additional questions for abdominal assessment

A
  • Bowel elimination
  • nausea, vomiting, diarrhea, constipation?
  • when was the last bowel movement
  • Bowel characteristics
  • Bowel color
  • is there a gastric tube present?
77
Q

Genitourinary assessment

A
  • is bladder distention present?
  • urine elimination( continent/ incontinent)
  • last void
  • Output characteristics( color, clarity, odor, amount)
  • is an indwelling catheter preset (assess for redness, irritation, drainage)
78
Q

Perineal (Pear-uh-knee-al) assessment

A
  • Don’t formally assess unless patient has complaints, is incontinent, or you are performing a procedure (catheter insertion)
  • Assess for redness, irritation, drainage, skin breakdown, cleanliness
79
Q

If patient is incontinent, has progressed dementia, dependent, or has an indwelling catheter how many times should you clean the perineal area thoroughly?

A

At least once per shift, if incontinent during brief change, during shower cleanse with soap and water, indwelling catheter cleanse area with soap and water

80
Q

Neurovascular assessment

A

is performed to evaluate sensory and motor function along with peripheral circulation of the extremities

81
Q

what is included in a neurovascular assessment?

A
  • Capillary refill
  • Peripheral pulses
  • Temperature
  • Color
  • Edema
  • Able to feel touch
  • Numbness
  • Tingling
82
Q

Capillary Refill

A

Used to determine blood flow to the peripheries/tissue

83
Q

Peripheral edema

A
  • Swelling in dependent extremities due to fluid build up/fluid overload
  • Swelling is caused by fluid leaking from vascular system to tissues (think of a sponge full of water)
84
Q

Edema (Pitting versus Non-Pitting)

A 
Non-Pitting Edema (Extremity appears swollen but does not indent when pressure applied)
Pitting Edema (Indentation occurs as pressure is applied to extremity)
85
Q

Pitting edema is graded on a scale:

A

1+: Mild; depression disappears rapidly
2+: Moderate; depression disappears in 10-15 seconds
3+: Moderately severe; depression disappears in about a minute
4+: Severe; depression can last for more than 2 minutes

86
Q

Determine the pulse strength

A

Absent: 0
Not present, EMERGENCY.
No blood flow to distal extremity. Notify provider immediately
Weak: 1+
Diminished, barely palpable
Peripheral vascular disease (decreased blood flow), decreased cardiac output
Strong: 2+
Able to feel with ease, appropriate/normal finding
Bounding: 3+
Full, think of booming bass/subwoofer
Fluid overloaded

87
Q

Pulses are

A

palpated bilaterally, simultaneously and compared for equality

88
Q

Radial pulse:

A

Thumb side of the wrist

and is the most commonly palpated

89
Q

Peripheral pulse locations:

A

Lower extremities such as femoral, popliteal, and dorsalis pedis pulse

90
Q

Neurovascular assessment

A
  • Temperature(warm, cool, cold, hot)
  • Color( pink, pale, cyanotic, deep rubor, purple/blue/brownish)
  • Sensation( able to feel touch?, numbness, tingling)
91
Q

It the patient injured an extremity or had surgery what should you use to asses them?

A

The 6 P’s if any are preset get help ASAP.

  1. Pain
  2. Parasthesia
  3. Pallor
  4. Paralysis
  5. Pulselessness
  6. Poikilothermia
92
Q

Overall skin assessment

A

-Color
-Temperature
-Moisture
-Integrity
-Turgor
-Edema
{Description in slide 71)

93
Q

Musculoskeletal assessment

A

-Joint swelling
-Range of motion(active, passive, full, partial)
{Description in slide 75)

94
Q

Questions that you should ask during a musculoskeletal assessment are…

A
  • Have you had any recent falls?

- Do you use an assistive device such as cane, walker, wheel-chair?

95
Q

Questions to ask yourself while doing a musculoskeletal assessment…

A
  • Does the patient need assistance standing?
  • Does the patient have a steady gait?
  • Can the patient have more than one assistive device?
  • how does the patient transfer from the bed to the chair? (independently, or requires assistance?)
96
Q

when assessing Gait you will state if the patient is……

A
  • Steady(with or without device)
  • Unsteady( with or without device)
  • Unable to ambulate
  • Unable to assess
97
Q

What are some different ways that you can assist a patient to stand and or transfer?

A
  • Use of a gait belt
  • 1 person
  • 2person
  • Stand by assist
  • Mechanical lift
98
Q

What are considered ADL’s

A
  • Bathing
  • Dressing
  • Toileting
  • Brushing Teeth
  • Brush Hair
  • Feeding Self
99
Q

What should you remember about ADL’s and patients?

A

Promote independence and encourage the patient to performed these instead of jumping to performing them for the patient

100
Q

Behavior, mood, psychosocial

A

You can pick up on behavior and mood pretty quickly during initial interactions (Can change throughout shift, if it does, document in the narrative)

101
Q

Behavior

A
  • Appropriate to situation

- Not appropriate to situation

102
Q

Mood

A
  • Calm
  • Anxious
  • Flat/Withdrawn
  • Tearful
  • Agitated
103
Q

Psychosocial

A

Current Smoker, Alcohol, Drug Use?

104
Q

Keep safety as a priority when working with patient

A

Side rails, wheelchair locked, fall mat in place, bed alarms, etc. and remember safety is documented at least every two hours

105
Q

When transferring or moving patient

A
  • Know the patient’s limitations
  • Determine if you need assistance in moving the patient
  • Ask patient to help as much as possible
  • Determine if patient comprehends what is expected
106
Q

Physical activity will:

A
  • Elevates mood and attitude.
  • Enables physical fitness.
  • Helps one to quit smoking and stay tobacco-free.
  • Boosts energy levels.
  • Helps in the management of stress.
  • Promotes a better quality of sleep.
  • Improves self-image and self-confidence.
107
Q

Physical activity (PA)

A

is any movement produced by skeletal muscles that results in energy expenditure.

108
Q

Physical exercise

A

is a subset of PA that is planned, structured, and repetitive and has a final or an intermediate objective, such as the improvement or maintenance of physical fitness.

109
Q

Assess patient’s activity tolerance

A
  • While the patient is performing in activity, are they tolerant to it?
  • Do they become dizzy, lightheaded, fatigued, SOB with activity?
110
Q

Within health care, physical therapists (PT)

A

focus on engaging patients in physical activity and exercise

111
Q

Body mechanics

A

Body alignment, balance, gravity, and friction all need to be considered when implementing nursing interventions
{Descriptions on slide 87}

112
Q

Skeletal system

A
  • Supporting framework for the body
  • Older adults are more susceptible to bone loss and osteoporosis, increasing the risk of fractures
  • Movement and exercise can strengthen bones
113
Q

Skeletal muscle

A
  • Immobile patients and/or those on prolonged bed rest will experience decreased activity level, decreased activity tolerance, and decreased muscle tone
  • Paralyzed patients without active muscle movement will experience muscle atrophy and contractures if the muscle/extremity isn’t passively moved
114
Q

Nervous system

A
  • Regulates movement and posture

- Controls body balance and alignment

115
Q

What should be a goal for nursing when a patient loses the ability to move a certain muscle?

A

To begin passive ROM ASAP

116
Q

SPHM

A

Safe patient handling and mobility

117
Q

What is the most common physical injury within nursing?

A

Back injuries

118
Q

Safe patient handling and mobility (SPHM)

A

involves improved assessment, the use of mechanical equipment, and safety procedures to lift and move patients

119
Q

What does the use of SPHM reduce and improve?

A

reduces injuries to health care workers and improves patient outcomes (ex. Fewer falls, skin tears, and pressure injuries)

120
Q

See steps for SPHM: Transferring a patient

A

slide 90-96

121
Q

If patient is ambulating for the first time since hospital admission, who should walk with them?

A

You! the nurse

122
Q

What should you do if a patient is falling?

A

-Do not try to catch them
-instead widen base of support with legs to support patients body weight.
-Allow patient to slide down while you hold the gait belt
-Gently set one floor
!This is still considered a Fall!

123
Q

Walkers

A
  • Used for lower extremity weakness or balance issues

- Some walkers have wheels: assist if patient cannot lift and advance the walker as they walk

124
Q

Canes

A

-Less support than walkers and less stable
-Cane should be used on stronger side of body
{Steps for use is on slide 102}

125
Q

Quad Cane

A

Provides the most support and is used with partial or complete leg paralysis or hemipleg

126
Q

Mobility and Immobility

A
  • Mobility refers to a person’s ability to move about freely,
  • immobility refers to the inability to do so
127
Q

Therapeutic intervention that restricts patients to bed for various reasons

A

Bed rest
(ex.Decreased oxygen demands of the body, allows body tissue to heal, Decreased cardiac workload and pain
,Allows patient to rest)

128
Q

Disuse atrophy

A

Cells and tissues decrease in size and function in response to prolonged inactivit

129
Q

Systemic effects of immobility: Metabolic changes

A
  • Decreased metabolic rate
  • Altered metabolism of macronutrients
  • Fluid and electrolyte imbalances
  • Gastrointestinal disturbances (decreased appetite, slowed peristalsis)
  • Calcium resorption (loss) from bones
130
Q

Systemic effects of immobility: Respiratory changes

A
  • Atelectasis

- Hypostatic pneumonia

131
Q

Why is it important that you limit bed rest and increase activity?

A
  • Promote self care activities, promote independence

* You should advocate for your patient!

132
Q

Loss of walking independence

A

increases hospital stays, need for rehabilitation services, requires nurse home placement

133
Q

Systemic effects of immobility: Cardiovascular changes

A
  • Orthostatic hypotension
  • Increased cardiac workload
  • Thrombus formation
134
Q

Systemic effects of immobility: Musculoskeletal changes

A
  • Impairment of musculoskeletal structures, reduced muscle mass
  • Disuse atrophy
  • Disuse Osteoporosis
135
Q

Systemic effects of immobility: Urinary elimination changes

A
  • Recumbent or supine position makes passing of urine difficult
  • Urinary stasis, increased risk for UTI development
  • Renal calculi present due to calcium resorption & hypercalcemia
136
Q

Systemic effects of immobility: Integumentary changes

A
  • Risk for skin breakdown and pressure injuries
  • Any break in the skin is difficult to heal
  • Prevention of pressure injuries is key
137
Q

Systemic effects of immobility: Psychosocial effects

A
  • Emotional and behavioral responses and changes in coping
  • Social isolation and loneliness
  • Every patient responds differently
138
Q

How often should you reposition a patient that is immobile or that is on bed rest?

A

At least every 2 hours, then document each time that you do.

139
Q

Safety Guidelines for Nursing Skills

A
  • Determine the amount and type of assistance required for safe positioning.
  • During positioning raise the side rail on the side of the bed opposite of where you are standing.
  • Arrange equipment so that it does not interfere with the positioning process.
  • Evaluate the patient for correct body alignment and pressure risks after repositioning.
140
Q

Just to give you a little laugh :)

What do you call a fake noodle?

A

AN IMPASTA!

BTW I cannot with myself muahahaha

The "Fun" class (12 decks)

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