Skills Exam 3 Flashcards
what is the purpose of a physical examination?
- 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
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. 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
C. a pattern of findings identified when the patient is first assessed
what are things that should be done to prepare for an examination?
- 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
How should you organize the assessment of each body system?
Using a Head to toe approach
what is important to know when doing a head to toe?
You should Perform painful procedures at the end
Head to toe tip!
compare sides for symmetry
Head to toe tip!
offer rest periods as needed
Head to toe tip!
Record quick notes during the examination; complete larger notes at the end of the examination
what types of techniques are used during a physical assessment?
- Inspection
- Auscultation
- Palpation
- Percussion
Observation made with eyes, ears, nose as soon as you walk into the room
Inspection
what should you watch for during the inspection phase of the assessment?
- Non verbal expressions
- asses emotional and mental status
- asses physical movements
During inspection you should….
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
Auscultation Requires:
- Good hearing
- a good stethoscope
- knowledge
- concentration and practice
what are sound characteristics to focus on during auscultation?
- Frequency
- loudness
- quality
- duration
Palpation
use of touch to gather information
what should be done when performing palpation?
- 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
Percussion
Tap the skin with fingertips to vibrate underlying tissues and organs.
what does the sound while doing percussion determine?
- location
- size
- density of structures
percussion is usually more performed by…
more advanced providers
General Survey
General appearance and behavior
Examples of General survey include
Gender, race, age, signs of distress, body type, posture, gait, movements, hygiene, dress, mood, speech, signs of abuse, substance abuse
Also included in General survey…..
- Vital signs
- height and weight
what is an assessment done to assess the level of consciousness?
AVPU
AVPU
- AWAKE and ALERT
- Responds to VERBAL stimuli
- Responds to PAINFUL stimuli
- UNCONCIOUS
When or why is the Glasgow coma scale used?
to asses a patients level of consciousness on a more deeper scale or more detailed scale (usually used in emergency settings and ICU units)
what number of the Glasgow coma scale is a good number meaning patient is responding perfectly
15
what number on the Glasgow coma scale means the patient is comatose?
<8 remember “less than 8, intubate”
Why is orientation assessed?
to determine if the patient is confused
It is good to have a baseline of a patients orientation why?
because if their orientation suddenly changes we can know something is wrong and we need to asses
What should you ask to asses orientation?
- Person
- Place
- Time
- Situation
If the patient is acutely confused what should you do?
use reality orientation to attempt to reorient them
If the patient is chronically confused( i.e. Dementia), what should you do?
you should avoid reorientation it can make the patient become agitated
why do we asses pupils?
to determine if the patients neurological response is appropriate
What should you find when assessing the pupils?
Both pupils should be the same shape, size and react to light equally
with what disease may the pupils react differently
With glaucoma, this would be expected
what should you check when assessing the pupils?
- Size
- Shape
- Reactivity to light
- consensual response
- accommodation
If all findings are within appropriate limits what do we call it?
PERRLA with consensual response present
PERRLA
Pupils Equal Round Reactive to Light with Accommodation(and consensual response)
Speech patterns/sounds
- Clear
- slurred
- garbled
- absent(non verbal)
Communication abilities
- Logical
- Illogical
Aphasia
the inability to communicate
Forms of aphasia
- 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
Inspecting head and face
- 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
EENT
- ears
- eyes
- nose
- throat
why do we Asses the ears?
to determine if there is any excessive drainage( ex: excessive cerumen)
What question should you ask especially if the patient is having trouble hearing?
Do you wear hearing aids?
If patient is hard of hearing you should…
speak up loudly and speak in short phrases, then provide appropriate time for the patient to respond
Eyes
- Are eyelids swollen
- color of sclera
- Glasses or no glasses( when do they wear them
Nose
- Septum( midline/deviated)
- Nares( patent/occluded)
- ask patient if they have any issues breathing through nose or mouth
Lips, oral mucosa, and teeth
- 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
Throat (Carotid artery and jugular vein)
-Visible pulsations of carotid artery?
-Juglar vein distention present in semi or high fowlers?
Indicate fluid overload
What is the function of the respiratory system?
- Oxygenation
- Gas exchange
Ventilation
- Movement of gases into and out of the lung
- Involves inspiration (inhale) and expiration (exhale)
Diffusion
Movement of oxygen and carbon dioxide between alveoli and red blood cells
Perfusion
Distribution of red blood cells to and from the pulmonary capillaries
Respirations
-Respiratory rate (Amount of respirations per minute) -Ventilatory effort (Unlabored or labored) -Ventilatory Pattern (Pattern of respirations Even or uneven)
If respirations are continuously shallow or deep (usually accompanied by labored breathing), assess patient thoroughly
- Respiratory distress?
- Just exercised? Winded?
- Anxiety attack? Hyperventilating?
What affects our respirations?
- Current output
- Exercise
- Anxiety
- Age
Respiratory assessment: inspection
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?
Respiratory assessment: Auscultation
- 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
Respiratory assessment: lung sounds
-Clear
-Diminished
-Crackles (Fine
Course)
-Rhonchi
-Wheezes
-Stridor
-Absent
If an adventitious sound is auscultated, you must be specific when you document
- 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?
Cough assessment
- 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
How long should you listen to heart sounds? and what do you listen for?
For at least 15 seconds to determine rate and rhythm and loudness of the the heart (strong or distant)
what should you do if the arterial pulse rate or rhythm is irregular?
assess the apical pulse( pulse found at the apex(bottom) of the heart)
What does the abdominal assessment include?
gastrointestinal system, genitourinary system, reproductive system (females)
Abdominal inspection
- Shape (distended, non distended)
- Also look for: Movements or pulsations, Colostomy, Wounds, bruising, incisions
Auscultation of the abdomen
Listen for the movement of contents through the bowels (Peristalsis) in a clockwise pattern
Bowel sounds: Normoactive
Normal sounds consist of clicks and gurgles and occur 5 to 34 per minute
Bowel sounds:Hypoactive
3 to 5 per minute; seen with decreased bowel motility
Bowel sounds:Hyperactive
- Greater than 34 sounds per minute.
- Caused by anxiety, infectious diarrhea, irritation of intestinal mucosa from blood, or gastroenteritis
Bowel sounds:Absent
- established only after 5 minutes of continuous listening in one quadrant.
- Caused by an immobile bowel
Palpation of the abdomen
should be performed last due to disruption of the bowel, ask the patient before performing if there is any pain present
what does palpation detect
- Tenderness
- distention
- masses
Additional questions for abdominal assessment
- Bowel elimination
- nausea, vomiting, diarrhea, constipation?
- when was the last bowel movement
- Bowel characteristics
- Bowel color
- is there a gastric tube present?
Genitourinary assessment
- 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)
Perineal (Pear-uh-knee-al) assessment
- 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
If patient is incontinent, has progressed dementia, dependent, or has an indwelling catheter how many times should you clean the perineal area thoroughly?
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
Neurovascular assessment
is performed to evaluate sensory and motor function along with peripheral circulation of the extremities
what is included in a neurovascular assessment?
- Capillary refill
- Peripheral pulses
- Temperature
- Color
- Edema
- Able to feel touch
- Numbness
- Tingling
Capillary Refill
Used to determine blood flow to the peripheries/tissue
Peripheral edema
- 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)
Edema (Pitting versus Non-Pitting)
Non-Pitting Edema (Extremity appears swollen but does not indent when pressure applied) Pitting Edema (Indentation occurs as pressure is applied to extremity)
Pitting edema is graded on a scale:
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
Determine the pulse strength
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
Pulses are
palpated bilaterally, simultaneously and compared for equality
Radial pulse:
Thumb side of the wrist
and is the most commonly palpated
Peripheral pulse locations:
Lower extremities such as femoral, popliteal, and dorsalis pedis pulse
Neurovascular assessment
- Temperature(warm, cool, cold, hot)
- Color( pink, pale, cyanotic, deep rubor, purple/blue/brownish)
- Sensation( able to feel touch?, numbness, tingling)
It the patient injured an extremity or had surgery what should you use to asses them?
The 6 P’s if any are preset get help ASAP.
- Pain
- Parasthesia
- Pallor
- Paralysis
- Pulselessness
- Poikilothermia
Overall skin assessment
-Color
-Temperature
-Moisture
-Integrity
-Turgor
-Edema
{Description in slide 71)
Musculoskeletal assessment
-Joint swelling
-Range of motion(active, passive, full, partial)
{Description in slide 75)
Questions that you should ask during a musculoskeletal assessment are…
- Have you had any recent falls?
- Do you use an assistive device such as cane, walker, wheel-chair?
Questions to ask yourself while doing a musculoskeletal assessment…
- 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?)
when assessing Gait you will state if the patient is……
- Steady(with or without device)
- Unsteady( with or without device)
- Unable to ambulate
- Unable to assess
What are some different ways that you can assist a patient to stand and or transfer?
- Use of a gait belt
- 1 person
- 2person
- Stand by assist
- Mechanical lift
What are considered ADL’s
- Bathing
- Dressing
- Toileting
- Brushing Teeth
- Brush Hair
- Feeding Self
What should you remember about ADL’s and patients?
Promote independence and encourage the patient to performed these instead of jumping to performing them for the patient
Behavior, mood, psychosocial
You can pick up on behavior and mood pretty quickly during initial interactions (Can change throughout shift, if it does, document in the narrative)
Behavior
- Appropriate to situation
- Not appropriate to situation
Mood
- Calm
- Anxious
- Flat/Withdrawn
- Tearful
- Agitated
Psychosocial
Current Smoker, Alcohol, Drug Use?
Keep safety as a priority when working with patient
Side rails, wheelchair locked, fall mat in place, bed alarms, etc. and remember safety is documented at least every two hours
When transferring or moving patient
- 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
Physical activity will:
- 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.
Physical activity (PA)
is any movement produced by skeletal muscles that results in energy expenditure.
Physical exercise
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.
Assess patient’s activity tolerance
- While the patient is performing in activity, are they tolerant to it?
- Do they become dizzy, lightheaded, fatigued, SOB with activity?
Within health care, physical therapists (PT)
focus on engaging patients in physical activity and exercise
Body mechanics
Body alignment, balance, gravity, and friction all need to be considered when implementing nursing interventions
{Descriptions on slide 87}
Skeletal system
- 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
Skeletal muscle
- 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
Nervous system
- Regulates movement and posture
- Controls body balance and alignment
What should be a goal for nursing when a patient loses the ability to move a certain muscle?
To begin passive ROM ASAP
SPHM
Safe patient handling and mobility
What is the most common physical injury within nursing?
Back injuries
Safe patient handling and mobility (SPHM)
involves improved assessment, the use of mechanical equipment, and safety procedures to lift and move patients
What does the use of SPHM reduce and improve?
reduces injuries to health care workers and improves patient outcomes (ex. Fewer falls, skin tears, and pressure injuries)
See steps for SPHM: Transferring a patient
slide 90-96
If patient is ambulating for the first time since hospital admission, who should walk with them?
You! the nurse
What should you do if a patient is falling?
-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!
Walkers
- Used for lower extremity weakness or balance issues
- Some walkers have wheels: assist if patient cannot lift and advance the walker as they walk
Canes
-Less support than walkers and less stable
-Cane should be used on stronger side of body
{Steps for use is on slide 102}
Quad Cane
Provides the most support and is used with partial or complete leg paralysis or hemipleg
Mobility and Immobility
- Mobility refers to a person’s ability to move about freely,
- immobility refers to the inability to do so
Therapeutic intervention that restricts patients to bed for various reasons
Bed rest
(ex.Decreased oxygen demands of the body, allows body tissue to heal, Decreased cardiac workload and pain
,Allows patient to rest)
Disuse atrophy
Cells and tissues decrease in size and function in response to prolonged inactivit
Systemic effects of immobility: Metabolic changes
- Decreased metabolic rate
- Altered metabolism of macronutrients
- Fluid and electrolyte imbalances
- Gastrointestinal disturbances (decreased appetite, slowed peristalsis)
- Calcium resorption (loss) from bones
Systemic effects of immobility: Respiratory changes
- Atelectasis
- Hypostatic pneumonia
Why is it important that you limit bed rest and increase activity?
- Promote self care activities, promote independence
* You should advocate for your patient!
Loss of walking independence
increases hospital stays, need for rehabilitation services, requires nurse home placement
Systemic effects of immobility: Cardiovascular changes
- Orthostatic hypotension
- Increased cardiac workload
- Thrombus formation
Systemic effects of immobility: Musculoskeletal changes
- Impairment of musculoskeletal structures, reduced muscle mass
- Disuse atrophy
- Disuse Osteoporosis
Systemic effects of immobility: Urinary elimination changes
- Recumbent or supine position makes passing of urine difficult
- Urinary stasis, increased risk for UTI development
- Renal calculi present due to calcium resorption & hypercalcemia
Systemic effects of immobility: Integumentary changes
- Risk for skin breakdown and pressure injuries
- Any break in the skin is difficult to heal
- Prevention of pressure injuries is key
Systemic effects of immobility: Psychosocial effects
- Emotional and behavioral responses and changes in coping
- Social isolation and loneliness
- Every patient responds differently
How often should you reposition a patient that is immobile or that is on bed rest?
At least every 2 hours, then document each time that you do.
Safety Guidelines for Nursing Skills
- 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.
Just to give you a little laugh :)
What do you call a fake noodle?
AN IMPASTA!
BTW I cannot with myself muahahaha
