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Skills Lecture > skills lecture 3 > Flashcards

skills lecture 3 Flashcards

1
Q

When you are doing a physical exam assessment how do you know if a change has occured?

A

compare to previous assessment done

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2
Q

what do you use a physical exam for?

A

-gather baseline data on pts health status
-compare to other assessments for change
-supplement, confirm, or refute subjective data obtained
-identify and confirm nursing diagnoses
-make clinical decisions about pts changing health status and management
-evaluate the outcomes of care
-better understand pts physical, mental and emotions needs as well as their educational needs

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3
Q

how do you prioritize which resident you will see first?

A

ABCs

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4
Q

ways to prepare for an examination

A

-infection control, ppe, gloves, disinfect equipment
-ensuring privacy in the environment
-make sure equipment works
-physical preparation of pt
-psychological prep of pt, explain what youre doing
-assessment of age groups
-maintain privacy
-educate and answer questions before performing a task
-inform patient of what you are doing before you do it (dont ask)

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5
Q

the organization of the examination is

A

assessment of each body system
systematic and organized
head to toe approach

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6
Q

THINGS TO DO IN HEAD TO TOE APPROACH

A

-COMPARE SIDES FOR SYMMETRY
-ASSESS BODY SYSTEMS MOST AT RISK FOR BEING ABNORMAL
-OFFER REST PERIODS AS NEEDED
-PERFORM PAINFUL PROCEDURES AT THE END
-BE SPECIFIC WHEN RECORDING ASSESSMENTS
-RECORD QUICK NOTES DURING THE EXAM AND COMPLETE LARGER NOTES AT THE END
-TRY TO REMEMBER WHAT WAS ABNORMAL ON THE ASSESSMENT

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7
Q

WHAT ARE THE TECHNIQUES OF PHYSICAL ASSESSMENT?

A

-INSPECT - LOOK
-AUSCULTATION - LISTEN
-PALATION - FEEL
PERCUSSION
ALWAYS DO IN THIS ORDER

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8
Q

FACTORS INVOLVED IN INSPECTION (LOOK)

A

-OBSERVATIONS MADE WITH EYES EARS NOSE WHEN YOU WALK IN THE ROOM
-HAVE GOOD LIGHTING AND DIRECT LIGHTING TO INSPECT BODY CAVATIES
-WATCH FOR NONVERBAL EXPRESSIONS, ASSESS EMOTIONAL AND MENTAL STATUS, ASSESS PHYSICAL MOVEMENTS
-INSPECT EACH AREA FOR SIZE, SHAPE, COLOR, SYMMETRY, POSITION AND ABNORMALITY
-CHECK FOR SIDE TO SIDE SYMMETRY
-POSITION AND EXPOSE BODY PARTS AS NEEDED SO ALL SURFACES CAN BE VIEWED BUT PRIVACY MAINTAINS

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9
Q

FACTORS INVOLVED IN AUSCULTATION (LISTEN)

A

REQUIRES: GOOD HEARING, A GOOD STETHOSCOPE, KNOWLEDGE, CONCENTRATION AND PRACTICE
SOUND CHARACTERISTICS: FREQUENCY, LOUDNESS, QUALITY AND DURATION

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10
Q

FACTORS INVOLVED IN PALPATION (TOUCH)

A

-USES TOUCH TO GATHER INFO
-USE DIFFERENT PARTS OF HAND TO DETECT DIFFERENT CHARACTERISTICS
-HANDS SHOULD BE WARM AND FINGERNAILS SHORT
-START WITH LIGHT PALPATION AND END WITH DEEP PALPATION
-ALWAYS PALPATE THE TENDER AREAS LAST

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11
Q

FACTORS INVOLVED WITH PERCUSSION

A

-TAP SKIN WITH FINGERTIPS TO VIBRATE UNDERLYING TISSUES AND ORGANS
-SOUND DETERMINES LOCATION, SIZE, AND DENSITY OF STRUCTURES
-PERFORMED BY A MORE ADVANCED PROVIDER

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12
Q

FACTORS WITH GENERAL APPEARANCE AND BEHAVIOR ON PHYSICAL EXAM

A

GENDER
RACE
AGE
SIGNS OF DISTRESS
BODY TYPE
POSTURE
GAIT
MOVEMENTS
HYGEIN
DRESS
MOOD
SPEECH
SIGNS OF ABUSE
SUBSTANCE ABUSE
VITALS SIGNS

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13
Q

IF A PATIENTS WEIGHT IS UNDER OR OVER WEIGHT IT COULD BE SIGNS OF WHAT?

A

UNDER - DEHYDRATION
OVER - RETAINING FLUIDS

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14
Q

WHAT ARE THE LEVELS OF CONSCIOUSNESS AND WHAT IS THE SCALE USED CALLED?

A

AVPU
AWAKE AND ALERT
RESPONDS TO VERBAL STIMULI
RESPONDS TO PAINFUL STIMULI
UNCONSCIOUS

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15
Q

IS THE PATIENT IS AWAKE AND ALERT HOW WOULD THEY RESPOND?

A

PATIENT OPENS EYE SPONTANEOUSLY AND IS AWAKE AND RESPONDING

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16
Q

IS THE PATIENT RESPONDS TO VERBAL STIMULI HOW WOULD THEY RESPOND?

A

-NOT AWAKE AND ALERT
-RESPONDS, OPENS EYES OR AWAKENS WHEN SPOKEN TO

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17
Q

IS THE PATIENT RESPONDS TO PAINFUL STIMULI HOW WOULD THEY RESPOND?

A

NOT AWAKE AND ALERT
DOES NOT RESPOND TO VERBAL STIMULI
- RESPONDS/OPEN EYES/AWAKENS WHEN THEY FEEL PAIN

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18
Q

IF A PATIENT IS UNCONSCIOUS HOW DO THEY RESPOND?

A

THEY DONT
UNRESPONSIVE TO STIMULI

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19
Q

WHAT IS USED IF A PATIENT IS NOT RESPONSIVE?

A

GALSGOW COMA SCALE

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20
Q

WHAT DOES GLASGOW COMA SCLAE EVALUATE?

A

EYE OPENING RESPONE
VERBAL RESPONSE
MOTOR RESPONSE

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21
Q

WHAT IS THE BEST SCORE OF THE GLASGOW COMA SCALE AND WHAT DOES IT MEAN?

A

BEST SCORE - 15
MEANS - PATIENT IS AWAKE, ALERT, ORIENTED AND FOLLOWING COMMANDS APPROPRIATELY

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22
Q

WHAT IS THE WORST SCORE OF THE GLASGOW COMA SCALE AND WHAT DOES IT MEAN?

A

SCORE - 3
MEANS - TOTALLY UNRESPONSIVE

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23
Q

WHAT DOES A SCORE OF 8 OR LESS ON THE GLASGOW COMA SCALE?

A

PATIENT IS COMATOSE
LESS THAN 8 - INTUBATE

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24
Q

WHEN AND WHERE IS THE GLASGOW COMA SCALE USED?

A

THE SCALE IS USED INEMERGENCY SETTINGS AND INTENSIVE CARE UNITS MOST FREQUENTLY

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25
Q

WHAT ARE THE TWO MAIN THINGS THAT CAUSE CONFUSION IN A PATIENT?

A

HYOXIA AND INFECTION

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26
Q

WHAT IS INVOLVED IN PATIENT ORIENTATION?

A

-PERSON
-PLACE
-TIME
-SITUATION

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27
Q

IF A PATIENT IS ACUTELY CONFUSED, USE ________ _________ TO ATTEMPT TO REORIENT THEM

A

REALITY ORIENTATION

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28
Q

IF THE PATIENT IS CHRONICALLY CONFUSED (DEMENTIA), REORIIENTATION MAY CAUSE THE PATIENT TO BECOME ________

A

AGITATED

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29
Q

WHAT IS THE REASON TO ASSESS FOR ORIENTATION?

A

TO DETERMINE IF A PATIENT IS CONFUSED OR NOT

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30
Q

ASSESSMENT OF THE PUPILS

A

ASSESS PUPILLARY RESPONSE
SHAPE, SIZE, AND REACT TO LIGHT EQUALLY

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31
Q

HOW TO ASSESS THE SIZE OF THE PUPILS

A

LOOK AT THE PUPILS; ARE THEY EQUAL OR UNEQUAL IN SIZE?
IF UNEQUAL MUST DOCUMENT THE SIZE OF EACH PUPIL
IF THIS IS A NEW FIND CONTACT THE PROVIDER

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32
Q

HOW TO ASSESS THE SHAPE OF THE PUPILS

A

LOOK AT THE PUPILS ARE THEY ROUND OR DIFFERENT SHAPE

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33
Q

HOW TO ASSESS THE REACTIVITY TO LIGHT

A

USE A PEN LIGHT TO SHINE IN EACH EYE WHILE ASSESSING FOR PUPILLARY REACTION/RESPONSE OF THE PUPIL THAT THE LIGHT IS DIRECTED TOWARDS.
ARE THE PUPILS REACTIVE? NONREACTIVE BILATERALLY? NON-REACTIVE UNILATERALLY?

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34
Q

HOW TO ASSESS CONSENSUAL RESPONSE OF PUPILS

A

USE PEN LIGHT TO SHINE IN ONE EYE, LOOK AT THE OTHER EYE AND ASSESS FOR PUPILLARY REACTION/RESPONSE.
IS THE CONSENTING? IS IT CONSTRICTING, JUST LIKE THE PUPIL WITH THE LIGHT SHINING IN IT IS? IF YES, CONSENSUAL RESPONSE IS PRESENT
CONSENSUAL RESPONSE: PRESENT? NOT-PRESENT BILATERALLY? NOT PRESENT UNILATERALLY?

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35
Q

HOW TO ASSESS ACCOMMODATION OF PUPILS

A

HOLD AND OBJECT CLOSE TO FACE AND HAVE PATIENT FOCUS ON IT, THEN HAVE THEM LOOK AT AN OBJECT FAR AWAY, THEN FOCUS BACK ON THE OBJECT CLOSE TO THEIR FACE
THE PUPILS SHOULD CONSTRICT WHEN FOCUSING ON AN OBJECT UP CLOSE, DILATE WHEN FOCUSING ON A FAR AWAY OBJECT
CAN ONLY ASSSESS THIS IF THE PATIENT IS COOPERATIVE. PRESENT OR NOT?

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36
Q

IF FINDINGS OF PUPILS ARE WITHIN APPROPRIATE LIMITS WHAT IS IT CALLED?

A

PERRLA WITH CONSENSUAL RESPONSE PRESENT

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37
Q

WHAT DOES PERRLA STAND FOR?

A

PUPILS EQUAL ROUND REACTIVE TO LIGHT WITH ACCOMMODATION
(AND CONSENSUAL RESPONSE)

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38
Q

If the patient is unable to perform accommodation HOW WOULD YOU DOCUMENT?

A

Must document everything and then describe why you’re unable to assess accommodation
Pupils equal round reactive to light with consensual response. Unable to assess accommodation, patient unable to follow commands

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39
Q

WHAT IS INVOLVED IN AN ASSESSMENT OF SPEECH?

A

PATTERNS AND SOUNDS
COMMUNICATION ABILITIES
APHASIA (INABILITY TO COMMUNICATE)

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40
Q

WHAT ARE THE CHARACTERISTICS OF SPEECH PATTERNS/SOUNDS?

A

CLEAR
SLURRED
GARBLED
ABSENT (NONVERBAL)

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41
Q

WHAT ARE THE CHARACTERISTICS OF SPEECH COMMUNCATION ABILITIES?

A

LOGICAL
ILLOGICAL

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42
Q

WHAT ARE THE CHARACTERISTICS OF SPEECH APHASIA

A

Sensory/receptive
Patient doesn’t understand the words being spoken to them. They are able to speak clearly, may be illogical
Motor/expressive – CANNOT SPEAK BUT RECEPTIVE
Patient cannot expressive themselves using verbal communication. They have difficulty forming words, their speech may be slurred and/or garbled. They are usually receptive of communication.

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43
Q

ASSESSMENT OF THE HEAD AND FACE INCLUDES

A

INSPECT
EENT

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44
Q

WHAT IS INVOLVED IN AN INSPECTION OF THE HEAD AND FACE?

A

-POSITION, SIZE AND SHAPE
-SYMMETRICAL FACIAL FEATURES

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45
Q

WHAT IS INVOLVED IN AN EENT ASSESSMENT?

A

EARS
EYES
NOSE
THROAT

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46
Q

WHAT IS INVOLVED IN AN EAR ASSESSMENT?

A

-CHECK INSIDE THE EARS FOR DRAINAGE
-DOES THE PATIENT WEAR HEARING AIDS?
-ANY HEARING DIFFICULTIES

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47
Q

IF A PATIENT HAS TROUBLE HEARING HOW SHOULD YOU CHANGE THE ASSESSMENT?

A

-QUIET AREA
-SPEAK UP
-SPEAK IN SHORT PHRASES
-GIVE RESIDENT TIME TO RESPOND

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48
Q

WHAT IS INVOLVED IN AN EYE ASSESSMENT?

A

-EYE LIDS
-SCLERA
-GLASSES

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49
Q

WHAT ARE YOU ASSESSING WHEN LOOKING AT THE EYE LIDS?

A

SWELLING

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50
Q

WHAT ARE YOU LOOKING AT WHEN ASSESSING THE SCLERA?

A

COLOR
WHITE - NORMAL
YELLOW- JAUNDICE
PINK - CONJUNCTIVA, IRRITATION
RED - IRRITATION, HEMORRHAGE OF VESSELS IN EYE

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51
Q

WHEN ASSESSING A RESIDENT YOU ARE CHECKING THEIR EYES. UPON QUESTIONING THE RESIDENT STATES THEY HAVE GLASSES BUT LEFT THEM AT HOME. WHAT WOULD THE NURSE DO WHEN ASSESSMENT IS OVER?

A

CONTACT SOMEONE THAT CAN BRING THE RESIDENT THEIR GLASSES

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52
Q

WHAT DOES AN ASSESSMENT OF THE NOSE INVOLVE?

A

SEPTUM
NARES

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53
Q

WHAT ARE YOU LOOKING FOR WHEN ASSESSING SEPTUM?

A

-MIDLINE
-DEVIATED

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54
Q

WHAT ARE YOU LOOKING FOR WHEN ASSESSING NARES?

A

-PATENT
-OCCLUDED

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55
Q

HOW DO YOU DETERMINE THE PATENCY OF EACH NARIS INDIVIDUALLY?

A

HAVE THE PATIENT OCCLUDE A NARIS AND BREATHE IN THROUGH THE NOSTRIL THEN REPEAT WITH THE OTHER SIDE

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56
Q

WHAT IS INVOLVED IN THE ASSESSMENT OF LIPS?

A

color
integrity

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57
Q

WHAT IS INVOLVED IN THE ASSESSMENT OF TEETH?

A

DENTURES?
TEETH PRESENT OR NOT PRESENT
IMPLORTANCE OF ORAL HYGEINE

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58
Q

IF A PATIENT IS MISSING ALL OF THEIR TEETH WHAT IS THIS CALLED?

A

EDENTULOUS

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59
Q

WHAT IS INVOLVED IN THE ASSESSMENT OF ORAL MUCOSA?

A

COLOR
MOISTURE
INTEGRITY

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60
Q

WHAT IS INVOLVED IN THE ASSESSMENT OF THE THROAT

A

CAROTID ARTERY AND JUGULAR VEIN

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61
Q

IF YOU CAN SEE THE JUGULAR VEIN DISTENDED WHEN SITTING IN SEMI OR HIGH FOWLERS POSITION WHAT DOES THIS INDICATE?

A

FLUID VOLUME OVERLOAD
HYPERVOLEMIA

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62
Q

MECHANISMS OF RESPIRATIONS?

A

VENTILATION
DIFFUSION
PERFUSION

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63
Q

WHAT OCCURS DURING VENTILATION?

A

MOVEMENT OF GASES INTO AND OUT OF THE LUNG, INVOLVES INSPIRATION AND EXPIRATION

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64
Q

WHAT OCCURS DURING DIFFUSION?

A

MOVEMENT OF OXYGEN AND CARBON DIOXIDE BETWEEN ALVEOLI AND RED BLOOD CELLS

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65
Q

WHAT OCCURS DURING PERFUSION?

A

DISTRIBUTION OF RED BLOOD CELLS TO AND FROM THE PULMONARY CAPILLARIES

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66
Q

WHAT ARE YOU LOOKING FOR WHEN ASSESSING RESPIRATIONS?

A

-RESPIRATORY RATE
-VENTILATORY EFFORT
-VENTILATORY PATTERN

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67
Q

IF RESPIRATIONS ARE CONTINUOUSLY SHALLOW OR DEEP WHAT ELSE SHOULD YOU ASSESS?

A

RESPIRATORY DISTRESS
JUST EXERCISED
WINDED
ANXIETY ATTACH
HYPERVENTILATING

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68
Q

WHAT AFFECTS RESPIRATIONS?

A

-CURRENT OUTPUT
-EXERCISE
-ANXIETY
-AGE

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69
Q

WHAT IS INVOLVED IN A RESPIRATORY ASSESSMENT?

A

INSPECTION
AUSCULTATION

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70
Q

WHAT IS INVOLVED IN AN INSPECTION OF RESPIRATORY ASSESSMENT?

A

USE EYES TO SEE:
-RATE, PATTERN, EFFORT
-POSITIONING
-COLOR OF LIPS, FINGER TIPS
-IS PATIENT WEARING OXYGEN IF SO WHAT DEVICE DO THEY USE AND HOW MANY LITERS

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71
Q

WHAT IS INVOLVED WITH AUSCULTATION ON A RESPIRATORY ASSESSMENT?

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

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72
Q

THINGS TO REMEMBER WHEN AUSCULTATING THE LUNGS?

A

When listening to anterior lower lobes, may need to ask women with large, pendulous breasts to lift them up, or have them raise their arms above their head (if they’re able to)
When listening to posterior upper lobes, be sure you are not listening over the scapula or the spine
When listening to posterior lower lobes, don’t go down too far (i.e. over the kidneys)

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73
Q

LUNG SOUNDS OF RESPIRATORY ASSESSMENT

A

-CLEAR
-DIMINISHED
-CRACKLES - FINE OR COURSE
-RHONCHI
-WHEEZES
-STRIDOR
-ABSENT

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74
Q

WHAT IS AN ADVENTIOUS SOUND OF THE LUNGS?

A

ANYTHING THAT IS NOT NORMAL WHEN ASSESSING THE LUNGS

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75
Q

IF YOU HEAR ADVENTIOUS LUNG SOUNDS WHAT MUST 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 AND WAS IT SUCCESSFUL OR NOT

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76
Q

CHARACTERISTICS OF COARSE CRACKLE LUNG SOUNDS AND CAUSE

A

MOIST BUBBLE SOUND, HEARD ON INSPIRATION AND EXPIRATION
CAUSE - FLUID IN AIRWAY

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77
Q

CHARACTERISTICS OF FINE CRACKLE LUNG SOUNDS AND CAUSE

A

VELCRO BRING TORN APART, HEARD AT END OF INSPIRATION
CAUSE- ALVEOLI POPPING OPEN ON INSPIRATION

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78
Q

CHARACTERISTICS OF WHEEZES ON LUNG SOUNDS AND CAUSE

A

FINE HIGH-PITCHED VIOLINS MOSTLY ON EXPIRATION
CAUSE- NARROWED AIRWAYS
*TYPICALLY WITH ASTHMA

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79
Q

CHARACTERISTICS OF STRIDOR LUNG SOUNDS AND CAUSE

A

LOUD CROWING NOISE HEARD WITHOUT STETHOSCOPE
CAUSE- AIRWAY OBSTRUCTION

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80
Q

CHARACTERISTICS OF DIMINISHED LUNG SOUNDS AND CAUSE

A

FAINT LUNG SOUNDS
CAUSES- DECREASED AIR MOVEMENT

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81
Q

CHARACTERISTICS OF ABSENT LUNG SOUNDS AND CAUSE

A

NO SOUNDS HEARD
CAUSE- NO AIR MOVEMENT

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82
Q

CHARACTERISTICS OF RHONCHI LUNG SOUNDS AND CAUSE

A

LOW PITCHED RATTLING SOUND, SIMILAR TO SNORING
CAUSE - OBSTRUCTION, SECRETIONS
*IF CLEARS WITH A COUGH IT IS CAUSED BY SECRETIONS

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83
Q

Patient has respiratory rate that is outside of expected normal values, breathing pattern is irregular, Depth of respirations increases or decreases, patient complains of dyspnea. What is your first step?

A

Observe for related factors such as obstructed airway; assess for abnormal breath sounds, productive cough, SOB, restlessness, irritability, anxiety, confusion

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84
Q

Patient has respiratory rate that is outside of expected normal values, breathing pattern is irregular, Depth of respirations increases or decreases, patient complains of dyspnea. What is your second step?

A

Help patient to supported sitting position (high Fowlers or tripod) unless contraindicated, which improves ventilation.

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85
Q

Patient has respiratory rate that is outside of expected normal values, breathing pattern is irregular, Depth of respirations increases or decreases, patient complains of dyspnea. What is your third step?

A

provide oxygen as ordered
titrate oxygen slowly until respiratory status improves

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86
Q

Patient has respiratory rate that is outside of expected normal values, breathing pattern is irregular, Depth of respirations increases or decreases, patient complains of dyspnea. What is your forth step?

A

report and document

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87
Q

Patient has respiratory rate that is outside of expected normal values, breathing pattern is irregular, Depth of respirations increases or decreases, patient complains of dyspnea. What is your fifth step?

A

continually reassess

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88
Q

what is involved in a cough assessment?

A

how frequent is the cough
how long has the cough been present
is it producing sputum
if cough is present assess cough abilities

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89
Q

characteristics of sputum production

A

coughing anything up
color: clear, yellow, green, pink, red (hemoptysis)
consistency: thick or thin

90
Q

what things should be encourage if sputum production is present?

A

deep breathing and coughing
fluids to thin secretions

91
Q

how will you assess coughing abilities if cough is present?

A

ask pt to cough
is cough weak or strong
if weak: encourage deep breathing to stimulate a stronger cough reflex and increase water to thin secretions

92
Q

A patient is admitted with pneumonia. When auscultating the patient’s chest, you hear low-pitched, continuous rattling sounds over the bronchi. These sounds are labelled as:
Course crackles.
Fine crackles
Rhonchi
Wheezes
Clear
Diminished

A

rhonchi

93
Q

assessment of the cardiovascular system involves:

A

-Heart sounds: S1 (LUB); S2 (DUB

94
Q

assessment of heart sounds

A

Listen for at least 15 seconds to determine rate and rhythm regularity
Listening for loudness of heart sounds, heart rate and heart rhythm

95
Q

characteristics of the loudness of heart sounds

A

strong or distant

96
Q

characteristics of the rate of heart sounds

A

regular and irregular

97
Q

characteristics of the rhythm of heart sounds

A

regular or irregular

98
Q

If heart rate and/or rhythm are outside of normal finding expectations what must the nurse assess?

A

apical pulse for one full minute

99
Q

heart rate <60bpm

A

bradycardia

100
Q

heart rate >100bpm

A

tachycardia

101
Q

what is it called when the heart rhythm is irregular?

A

dysrhythmia

102
Q

what are the signs and symptoms of a dysrhythmia?

A

lightheaded and dizzy
are blood pressure and respiratory rate/effort normal or abnormal

103
Q

how do you find the apical pulse?

A
  1. Have the patient sit or lay down
  2. Find the sternal notch, located in between the clavicles
  3. Find the angle of louis, right below the sternal notch
  4. Move your hand slightly to their left side, and begin to count intercostal spaces (you begin at space #2)
  5. Once you find the fifth intercostal space, move your hand so that it is midclavicle
  6. Place the diaphragm of your stethoscope in this location, place firmly and securely on chest
  7. Each “lub-dub” is one beat, count for 60 seconds to determine accurate heart rate
104
Q

what is the difference between the radial and apical pulse called?

A

pulse deficit

105
Q

Apical or radial pulse is greater than 100 beats/min what do you do?

A

Identify related data, including fever, anxiety, pain, recent exercise, hypotension, decreased oxygenation, or dehydration
Observe for signs and symptoms of inadequate cardiac output, including fatigue, chest pain, orthopnea, cyanosis, and dizziness.
Report and document

106
Q

Apical or radial pulse is less than 60 beats/min what do you do?

A

Assess for factors that alter heart rate such as beta-blockers and antidysrhythmic medications.
Observe for signs and symptoms of inadequate cardiac output, including fatigue, chest pain, orthopnea, cyanosis, dizziness.
Report and document

107
Q

Apical or radial pulse irregular

A

Observe for symptoms associated with decreased tissue perfusion, including pallor and cool skin temperature of tissue distal to the weak pulse.
Measure apical and radial pulse simultaneously to determine presence of pulse deficit.
Report and document

108
Q

when doing a head to toe assessment why is the abdominal assessment so complex?

A

because the organs are located in the abdominal cavity

109
Q

an abdominal assessment includes which systems?

A

-gastrointestinal system
-genitourinary system
-reproductive system in females

110
Q

how to do an abdominal inspection

A

-place pt in supine position (can be done sitting down but if abnormal move pt to supine position
-lift clothing to assess bare stomach
-inspect shape of stomach

111
Q

when inspecting the shape of the stomach what are you looking for?

A

-non-distended - flat, round
-distended - round and firm, tight
-masses
-enlarged organs - bladder or intestines fill
-also look for: movements or pulsations, colostomy, wounds, bruising, incisions

112
Q

AUSCULTATION OF THE ABDOMEN

A

-LISTEN FOR MOVEMENT OF CONTENTS THROUGH THE BOWELS (PERISTALSIS) IN A CLOCKWISE PATTERN
-Place your stethoscope on the RLQ and begin clock at 0. When first bowel sound is heard, stopwatch time. That is how long the bowel sounds are in that quadrant.

113
Q

HOW DO YOU CATEGORIZE BOWEL SOUNDS?

A

NORMOACTIVE
HYPOACTIVE
HYPERACTIVE
ABSENT

114
Q

NORMAL BOWEL SOUNDS CONSIST OF CLICKS AND GURGLES AND OCCUR 5 TO 34 PER MINUTE

A

NORMOACTIVE

115
Q

3 TO 5 BOWEL SOUNDS PER MINUTE; SEEN WITH DECREASED BOWEL MOTILITY

A

HYPOACTIVE

116
Q

BOWEL SOUNDS GREATER THAN 34 SOUNDS PER MINUTE CAUSED BY ANXIETY, INFECTIOUS, DIARRHEA, IRRITATION OF INTESTINAL MUCOSA FROM BLOOD OR GASTROENTERITIS

A

HYPERACTIVE

117
Q

NO BOWEL SOUNDS AFTER LISTENING FOR 5 MINUTES CONTINOUSLY IN ONE QUADRANT AND IS CAUSED BY AN IMMOBILE BOWEL

A

ABSENT

118
Q

PALPATION OF ABDOMEN

A

LIGHTLY PALPATE INN A CLOCKWISE MANNER USUALLY START IN THE RIGHT LOWER QUADRANT OR RIGHT UPPER QUADRANT

119
Q

PRIOR TO PALPATING THE ABDOMEN WHAT SHOUDL YOU ASK THE PATIENT?

A

IF THEY ARE EXPERIENCING ANY PAIN
IF SO PALPATE THE AREA LAST

120
Q

WHAT DOES PALPATION DETECT?

A

TENDERNESS
DISTENTION
MASSES

121
Q

IF YOU PALPATE ABDOMEN BEFORE YOU AUSCULTATE WHAT COULD HAPPEN?

A

DISRUPT THE BOWEL

122
Q

ADDITIONAL QUESTIONS ABOUT CHARACTERISTICS OF BOWELS

A

BOWEL ELIMINATION
N/V, DIARRHEA OR CONSTIPATION
LAST BOWEL MOVEMENT
BOWEL CHARACTERISTICS
BOWEL COLOR
GASTRIC TUBE PRESENT

123
Q

WHAT DO YOU NEED TO KNOW WHEN ASKING A RESIDENT ABOUT BOWEL ELIMINATION

A

CONTINENT
INCONTINENT
COLOSTOMY OR ILLESTOMY PRESENT

124
Q

WHAT DO YOU NEED TO KNOW WHEN ASKING A RESIDENT ABOUT N/V, DIARRHEA OR CONSTIPATION

A

WHEN DID IT START
FREQUENCY
ABILITY TO KEEP FLUIDS IN

125
Q

WHAT DO YOU NEED TO KNOW WHEN ASKING A RESIDENT ABOUT LAST BOWEL MOVEMENT

A

WHEN WAS IT
WHAT ARE THE RESIDENTS REGULAR BOWEL HABITS

126
Q

WHAT DO YOU NEED TO KNOW WHEN ASKING A RESIDENT ABOUT BOWEL CHARACTERISTICS

A

SOFT
FIRM
HARD
LOOSE
WATERY

127
Q

WHAT DO YOU NEED TO KNOW WHEN ASKING A RESIDENT ABOUT BOWEL COLOR

A

BROWN
GREEN
BLACK
RED

128
Q

WHAT DO YOU NEED TO KNOW WHEN ASKING A RESIDENT ABOUT PRESENT GASTRIC TUBE

A

NG TUBE
PEG TUBE

129
Q

ASSESSMENT OF THE BLADDER INCLUDES:

A

INSPECTION
PALPATE TO SEE IF BLADDER DISTENTION IS PRESENT
URINE ELIMINATION

130
Q

ASSESSMENT OF URINE ELIMINATION

A

CONTINENT OR INCONTINENT
LAST VOID

131
Q

IF A PATIENT IS INCONTINENT WHAT ARE THEY AT RISK FOR?

A

-SKIN BREAKDOWN OF THE PERINEAL, BUTTOCKS, COCYX AND SACRUM
-UTI

132
Q

HOW OFTEN SHOULD AN INCONTINENT RESIDENTS BRIEF BE CHECKED

A

EVERY TWO HOURS

133
Q

CHARACTERISTICS OF URINARY OUTPUT

A

COLOR
CLARITY
ODOR
DYSURIA
AMOUNT

134
Q

IF A PATIENT HAS AN INDWELLING CATH PRESENT WHAT SHOULD YOU ASSESS FOR?

A

URINE OUTPUT, KINKS IN TUBING
ASSESS INSERTION SITE FOR REDNESS, IRRITATION OR DRAINAGE

135
Q

IF OUTPUT OF URINE IS BEING MEASURED HOW DO YOU RECORD IT WHEN DOCUMENTING?

A

IN MILLIMETERS

136
Q

IF A PATIENT IS INCONTINENT HOW DO YOU RECORD URINATION OUTPUT?

A

BY OCCURENCES
(X1 OCCURENCE)

137
Q

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

A

neurovascular assessment

138
Q

what is checked during a neurovascular assessment?

A

capillary refill
peripheral pulses
temp
color
edema
able to feel touch
numbness
tingling

139
Q

SWELLING IN DEPENDENT EXTREMITIES DUE TO FLUID BUILD UP/FLUID OVERLOAD CAUSED BY FLUID LEAKING FROM VASCULAR SYSTEM TO TISSUES

A

PERIPHERAL EDEMA

140
Q

TYPES OF EDEMA

A

PITTING
NON-PITTING

141
Q

PITTING EDEMA SCALE:

A

1+ - MILD DISAPPEARS RAPIDLY
2+ - MODERATE; DISAPPEARS IN 10-15 SECONDS
3+ 0 MODERATELY SEVERE DISAPPEARS IN ABOUT A MINUTE
4+ SEVERE CAN LAST MORE THAN 2 MINUTES

142
Q

HOW IS NON PITTING EDEMA MEASURED

A

TAPE MEASURE THE CIRCUMFERENCE OF THE SWOLLEN AREA

143
Q

PERIPHERAL PULSE NEEDS TO BE DONE HOW TO THE BODY?

A

SYMMETRICALLY

144
Q

HOW DO YOU DOCUMENT THE PULSE STRENGTH?

A

0 - ABSENT
1+ WEAK
2+ STRONG
3= BOUNDING

145
Q

IF A PATIENT HAS A BOUNDING PULSE WHAT DOES THIS INDICATE?

A

FLUID OVERLOAD

146
Q

IF A PATIENT HAS AN ABSENT PULSE STRENGTH WHAT DOES THIS INDICATE

A

NO BLOOD FLOW TO DISTAL EXETREMITY
THIS IS AN EMERGENCY AND PROVIDER NEEDS TO BE NOTIFIED IMMEDIATELY

147
Q

IF A PATIENT HAS A WEAK PULSE WHAT DOES THIS INDICATE?

A

PERPHERAL VASCULAR DISEASE (DECREASED BLOOD FLOW), DECREASED CARDIAC OUTPUT

148
Q

IF A PATIENT HAS A STRONG PULSE WHAT DOES THIS INDICATE?

A

NORMAL.APPROPRIATE FINDING

149
Q

WHICH PULSE IS NOT PALPATED SIMULTANEOUSLY?

A

CAROTID PULSES

150
Q

6 Ps of arterial occlusion

A

pain
parethesia
pallor
paralysis
pulselessness
poikilothermia

151
Q

While this is expected with a muscle injury, pain described as deep and constant and poorly localized, that increases when stretching or manipulating the muscle, and is unrelieved by pain medications is not normal! What is this a sign of?

A

pain with an arterial occlusion

152
Q

The patient may experience a pins-and-needles sensation, tingling, tickling, prickling or burning. Due to lack of oxygen supply to tissue/muscle. what is this a sign of?

A

paresthesia with an arterial occlusion

153
Q

If you notice that your patient has pale, shiny skin, especially distal to the injury site, report the symptoms to a doctor immediately. Due to lack of oxygen supply to tissue/muscle. What is this a sign of?

A

pallor with arterial occlusion

154
Q

numbness in a limb can be a sign of arterial occlusion. This is most common when a patient’s leg or arm has been crushed in an accident. what is this a sign of

A

paralysis with an arterial occlusion

155
Q

A diminished or absent pulse in an affected area which creates a tourniquet-like effect and cuts off circulation to the limb. Due to lack of oxygen supply to tissue/muscle

A

pulselessness with an arterial occlusion

156
Q

This term, which refers to a body part that regulates its temperature with surrounding areas, is an important one. If you notice a limb that feels cooler than surrounding areas. what is this a sign of?

A

poikilothermia with an arterial occlusion

157
Q

Because of an older adults skin becoming frail what should you be cautious of putting on their skin?

A

tape

158
Q

what is involved in an overall assessment of the skin?

A

color
temp
moisture
integrity
turgor
edema

159
Q

IF A PATIENT’S SKIN IS DUSKY IN COLOR WHAT CAN THAT INDICATE?

A

HYPOXIA

160
Q

IN A CLINICAL SETTING YOU WILL SEE RESIDENTS RANGE OF MOTION WHEN THEY DO WHAT

A

ADLS

161
Q

A PATIENT CAN MOVE EXTREMITIES ON THEIR OWN

A

ACTIVE RANGE OF MOTION

162
Q

PATIENT CANNOT MOVE EXTREMITIES ON THEIR OWN, NEED ASSISTANCE

A

PASSIVE RANGE OF MOTION

163
Q

EXTREMITIES HAVE NO LIMITATIONS ON MOVEMENT

A

FULL RANGE OF MOTION

164
Q

EXTREMITIES HAVE LIMITATIONS ON MOVEMENT, CAN ONLY MOVE TO A PARTICULAR POSITION AND THEN RESISTANCE NOTE, MOVE EXTREMITY/JOINT JUST TO THE POINT OF RESISTANCE, THEN STOP

A

PARTIAL RANGE OF MOTION

165
Q

STIFF BODY PARTS THAT DO NOT MOVE, USUALLY FROM ATROPHY OF MUSCLES AND LACK OF USE, OCCURS WHEN PARALYZED

A

CONTRACTURES

166
Q

WHEN ASSESSING PATIENTS ABILITIES TO MOVE WHAT QUESTIONS NEED TO BE ASKED?

A

RECENT FALLS?
ASSISTIVE DEVICES?
HOW DOES THE PATIENT TRANSFER FROM BED TO CHAIR

167
Q

WHAT DO YOU NEED TO ASK PATIENT BEFORE AMBULATING?

A

RECENT FALLS
ASSISTIVE DEVICES
TRANSFER ABILITIES
DIZZY OR LIGHTHEADED
DO THEY FEEL COMFORTABLE WALKING
PAIN

168
Q

TRANSFER TECHNIQUES

A

USE A GAITBELT
SAFE ENVIRONMENT
1 PERSON
2 PERSON
STAND BY ASSIST
MECHANICAL LIFT

169
Q

ACTIVITIES OF DAILY LIVING

A

BATHING
DRESSING
TOILETING
BRUSHING TEETH
BRUSH HAIR
FEEDING SELF

170
Q

BEHAVIOR IN AN ASSESSMENT

A

APPROPRIATE OR NOT APPROPRIATE TO SITUATION
-VULGAR, RUDE OR HOSTILE, CURSING
CAN CHANGE THROUGHOUT SHIFT IF IT DOES DOCUMEENT IN THE NARRATIVE

171
Q

MOOD IN ASSESSMENT

A

CALM
ANXIOUS
FLAT/WITHDRAWN
TEARFUL
AGITATED
-CAN CHANGE THROUGHOUT THE SHIFT IF IT DOES DOCUMENT IN THE NARRATIVE

172
Q

PSYCHOSOCIAL ASSESSMENT

A

CURRENT SMOKER
CURRENT ALCOHOL USE
CURRENT DRUG USE

173
Q

KEEP ______ A PRIORTY WHEN WORKING WITH PATIENT

A

SAFETY

174
Q

EXAMPLES OF SAFETY MEASURES NURSE NEEDS TO CHECK

A

SIDE RAILS
WHEELCHAIR LOCKED
FULL MAT IN PLACE
BED/CHAIR ALARMS

175
Q

SAFETY MEASURES WHEN TRANSFERRING A PATIENT

A

KNOW THE PTS LIMITATIONS
DEETERMINE IF YOU NEED ASSISTANCE
ASK PT TO HELP AS MUCH AS POSSIBLE
DETERMINE IF PT COMPREHENDS WHAT IS EXPECTED

176
Q

SAFETY MEASURE WITH OXYGEN

A

IS PT USING O2
IS TANK FULL
NO SMOKING WITH O2
MAKE SURE PT DOES NOT FALL ON TUBING

177
Q

HOW OFTEN DOES SAFETY NEED TO BE DOCUMENTED?

A

AT LEAST EVERY TWO HOURS

178
Q

WHAT AFFECTS DOES PHYSICAL ACTIVITY HAVE ON A PERSON?

A

ELEVATES MOOD AND ATTITUDE
ENABLES PHYSICAL FITNESS
HELPS ONE TO QUIT SMOKING AND STAY TOBACCO FEE
BOOSTS ENERGY LEVELS
HELPS IN THE MANAGEMENT OF STRESS
PROMOTES A BETTER QUALITY OF SLEEP
IMPROVES SELF IMAGE AND SELF CONFIDENCE

179
Q

decrease in the ability to perform self care or ADLs. If you don’t use it you lose it. Allow resident to do what the can.

A

FUNCTIONAL DECLINE

180
Q

WHAT CAUSES FUNCTIONAL DECLINE

A

ILLNESS
PHYSICAL INACTIVITY

181
Q

any movement produced by skeletal muscles that results in energy expenditure

A

PHYSICAL ACTIVITY

182
Q

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

A

PHYSICAL EXERCISE

183
Q

PROPER BODY ALLIGNMENT ALLOWS FOR A STABLE _____ __ _______

A

CENTER OF GRAVITY

184
Q

HOW SHOULD A PATIENT BE MOVED IN THE BED?

A

WITH TWO PEOPLE USING A DRAW SHEET TO AVOID SKIN TEARS

185
Q

________ SYSTEM AND __________ system must work together to produce coordinated body movement

A

MUSCOSKELETAL AND NERVOUS

186
Q

WHAT IS THE NUMBER ONE WAY TO PREVENT OSTEOPORISIS

A

MOVEMENT AND EXERCISE

187
Q

WHAT DO PARALYZED PATIENTS WITHOUT ACTIVE MUSCLE MOVEMENT EXPERIENCE?

A

MUSCLE ATROPHY AND CONTRACTURES

188
Q

THE GOAL FOR NURSING IS TO BEGIN PASSIVE ROM EXERCISES FOR PATIENTS THAT LOSE THE ABILITY TO MOVE A CERTAIN MUSCLE IS WHEN?

A

AS SOON AS THEY LOSE THE ABILITY

189
Q

WHAT IS SPHM?

A

SAFE PATIENT HANDLING AND MOBILITY

190
Q

WHAT IS SAFE PATIENT HANDLING AND MOBILITY USED FOR?

A

IMPROVES ASSESSMENT, THE USE OF MECHANICAL EQUIPMENT, AND SAFETY PROCEDURES TO LIFT AND MOVE PATIENTS
STANDARD FOR BEST PRACTICES IN THE MOVING, HANDLING, AND TRANSFER OF PATIENTS
REDUCES INJURIES TO HEALTH CARE WORKERS AND IMPROVES PATIENT OUTCOMES

191
Q

WHAT DOES SPHM PREVENT?

A

FALLS
SKIN TEARS
PRESSURE INJURIES

192
Q

HOW MANY PEOPLE ARE NEEDED TO USE A LIFT TO TRANSFER PATIENTS?

A

A MINIMUM OF TWO PEOPLE

193
Q

THINGS TO REMEMBER WHEN USING A LIFT

A

EDUCATE PATIENT
UNDERSTAND HOW LIFT WORKDS
ENSURE BATTERY IS CHARGED
ENSURE ENOUGH PEOPLE PRESENT TO HELP

194
Q

THINGS TO REMEMBER WHEN TRANSFERRING AND POSITIONING PT?

A

MAKE SURE PT IS SAFE
MAKE SURE PT IS COMFORTABLE

195
Q

WHAT SHOULD BE IMPLEMENTED WHEN USING MOBILITY

A

ENCOURAGE PHYSICAL ACTIVITY AS OFTEN AS POSSIBLE
ISOMETRIC EXERCISES
RANGE OF MOTION EXERCISES
AMBULATE PT

196
Q

IF A PATIENT IS IMMOBILE WHAT ORGANS CAN IT AFFECT?

A

HEART AND LUNGS

197
Q

WHEN A PATIENT BEGINS TO FALL WHEN AMBULATING WHAT SHOULD THE NURSE DO?

A

HELP LOWER PT TO THE GROUND DO NOT ATTEMPT TO CATCH THEM

198
Q

TYPES OF ASSISTED DEVICES FOR AMBULATING

A

WALKER
CANE
QUAD CANE
gaitbelt

199
Q

WHAT IS A WALKER USED FOR?

A

EXTREMITY WEAKNESS OR BALANCE ISSUES

200
Q

HOW TO USE A WALKER

A

GRIP HANDLBARS, TAKE A STEP, MOVE WALKER FORWARD THEN TAKE ANOTHER STEP

201
Q

CANES SUPPORT

A

LESS SUPPORT THAN WALKER AND LESS STABLE

202
Q

HOW TO USE A CANE

A

ADVANCE CANE FORWARD AND POSITION ON GROUND, STEP FORWARD WITH WEAKER LEG (SO BODY WEIGHT IS DIVIDED BETWEEN CANE AND STRONG LEG)
THEN ADVANCE STRONGER LEG PAST CANE SO WEAKER LEG AND BODY WEIGHT ARE SUPPORTED AGAIN

203
Q

QUAD CANE SUPPORT

A

PROVIDES THE MOST SUPPORT AND IS USED WITH PARTIAL OR COMPLETE LEG PARALYSIS OR HEMIPLEGIA

204
Q

WHO HAS TO ORDER ASSISTIVE DEVICES

A

DR OR PHYSICAL THERAPIST

205
Q

PHYSICAL THINGS THAT IMMOBILITY CAUSES

A

LUNGS
HEART
SKIN
EMOTIONAL STATUS CHANGES

206
Q

Therapeutic intervention that restricts patients to bed:

A

DECREASED OXYGEN DEMANDS OF THE BODY, ALLOWS BODY TISSUE TO HEAL
DECREASED CARDIAC WORKLOAD AND PAIN
ALLOWS PATIENT TO REST

207
Q

Effects of muscular deconditioning associated with lack of physical activity happen how soon?

A

in a matter of days if not used

208
Q

affects on a person when muscle decondition is happening

A

disuse atrophy
physiological
psychological
social - losing a job

209
Q

Metabolic changes due to mobility

A

decreased metabolic rate
altered metabolism of macronutrients
fluid and electrolyte imbalances
gastrointestinal disturbances
calcium loss from bones
respiratory changes

210
Q

what type of diet should be implemented when a pt is immobile

A

high protein and calories

211
Q

what gastrointestinal disturbances occur with immobility

A

constipation (peristalsis increased with movement)
possible fecal impaction

212
Q

changes that occur with calcium resorption from bones with immobility

A

release of calcium into circulation
hypercalcemia may result if kidneys arent functioning appropriately and can affect the heart

213
Q

what occurs with respiratory changes with immobility

A

atelectasis
hypostatic pneumonia

214
Q

if a patient is immobile and having respiratory changes what should you do

A

turn, cough, deep breathe

215
Q

Cardiovascular changes with mobility

A

Orthostatic hypotension – low blood pressure with movement caused by the decreased circulation of fluid and blood
Increased cardiac workload when prolonged periods of immobility
Heart works harder and less efficiently during periods of prolonged rest
Decreased profusion
Thrombus formation
At risk for? Blood clots/pulmonary embolism – can use range of motion to help with profusion
Can start with profusion but lead to respiratory problem

216
Q

Musculoskeletal changes with mobility

A

Impairment of musculoskeletal structures, reduced muscle mass
Disuse atrophy
Disuse Osteoporosis
Bone resorption
Calcium leaves the bones and goes into the blood stream/circulation. Bones weak because calcium left bones.
Hypercalciumia occurs because the calcium is now in the blood

217
Q

Urinary elimination changes with immobility

A

Recumbent or supine position makes passing of urine difficult
Urinary stasis bacteria grows, increased risk for UTI development
Renal calculi present due to calcium resorption & hypercalcemia – causes kidney stones

218
Q

Integumentary changes with immobility

A

Risk for skin breakdown and pressure injuries
Reposition at least every two hours  document each time!
Any break in the skin is difficult to heal – protein and calories will help skin heal
Prevention of pressure injuries is key

219
Q

Psychosocial effects with immobility

A

Emotional and behavioral responses and changes in coping
Social isolation and loneliness
Every patient responds differently

220
Q

Safety Guidelines for Nursing Skills
positioning

A

-determine the amount and type of assistance required for safe positioning determine by pt height and weight
-during positioning raise the side rail on the bed opposite side of where you are
-arrange equipment in the room so it doesnt interfere with the positioning process
-evaluate the patient for correct body alignment and pressure risks after repositioning use pillows

Skills Lecture (7 decks)

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