Unit 2 Patient Assessment and Monitoring Flashcards
Essential Skills of Patient Assessment
•Observation
•Evaluation
•Assessment
•Communication
➢Relaying information
AIDET
•A = Acknowledge
•I = Introduce
•D = Duration
•E = Explanation
•T = Thanks
Taking a History and it’s elements
•Questioning techniques
➢Open-ended questions
➢Facilitation
➢Silence
➢Reflection or reiteration
➢Clarification or probing
➢Summarization
Elements of a History
•Onset
•Duration/chronology
•Specific location
•Quality of symptoms
•Severity of pain
•What aggravates/alleviates
•Associate manifestations
History: Onset Sample Questions
•How did it start?
•What happened?
•When did it first trouble you?
•Was it sudden or a complaint that gradually became worse?
History: Duration/Chronology Sample Questions
•Have you ever experienced it before?
•Has it been continuous?
•Does it bother you all the time?
•How long has this attack been bothering you?
History: Location Sample Questions
•Where does it hurt (or where is the problem)?
•Can you put your finger where it hurts the most?
•Does it hurt anywhere else?
History: Quality of Symptoms Sample Questions
•What does it feel like?
➢Sharp, stabbing pain?
➢Dull ache?
➢Throbbing pain?
History: Severity of Pain Sample Questions
•How severe is it?
•Mild, moderate, or severe?
➢Some like to use a pain scale of 1–5 or 1–10, with 0 being no pain at all and the highest number representing the worst pain the patient can imagine.
•Does it wake you up at night?
History: What Aggravates Sample Questions
•What seems to make it worse?
•When is it worst?
•Is it worse after meals?
•At night?
•When you walk?
History: What Alleviates Sample Questions
•What has helped in the past?
•Does that still help?
•What seems to help now?
•Does the time of day (amount of rest, change in position, and so on) make a difference?
History: Associated Manifestations
•Are there any other symptoms that you are experiencing that are associated with your chief complaint?
Assessing Current Physical Status
•Checking the chart
➢Obtain more specific information.
•Physical assessment
➢An ongoing process of observation, comparison, and measurement of patient’s condition before, during, and after imaging procedures
•Vital signs
➢Temperature, pulse rate, respiratory rate, and blood pressure
Standardized Color-Code Medical Alert Wristbands
-DNR(Do Not Resuscitate): purple
-Allergy: red
-Fall risk: yellow
Physical Appearance and Responses
•Skin color and temperature
•Level of consciousness (LOC)
•Breathing
Temperature
Digital, electronic thermometer for taking oral, axillary, and rectal temperature
Tympanic temperature probe
Inserted into external ear canal
Temporal artery thermometer
➢Contains an infrared sensor
➢Measures over the temporal artery in the forehead
➢Easy and quick; not objectionable to patients
➢Research indicates that this method is more accurate than the tympanic method.
Pulse is measured in? Tachycardia vs Bradycardia
•Measured in beats per minute (BPM)
•Tachycardia
➢Heart rate that is too fast(150-250 bpm)
•Bradycardia
➢Heart rate that is too slow
Respirations count? Normal range? Bradypnea vs Tachypnea
number of breaths per minute
•Normal range = 12–20 breaths/min
•Bradypnea
➢Fewer than 12 breaths/min
•Tachypnea
➢More than 20 breaths/min
Blood Pressure and it’s normal range
•Measured with sphygmomanometer
•Expressed as:
➢Systolic (A)
➢Diastolic (B)
•Normal range
➢Systolic = 95–119
➢Diastolic = 60–79
Blood Pressure: Hypertension
High blood pressure
➢Two stages
•Stage 1—systolic ranges 140–159 mm Hg; diastolic ranges 90–99 mm Hg
•Stage 2—the most severe form, Systolic reading is 160 mm Hg or greater and diastolic is 100 mm Hg or greater.
Blood Pressure: Hypotension
Low blood pressure
➢Diastolic pressure <50 mm Hg or systolic pressure <90 mm Hg
➢May also indicate shock
Common Laboratory Tests for Patient Assessment
•Complete Blood Count
•Erythrocyte Sedimentation Rate
•Blood-Clotting Assessments
•Blood-Chemistry Tests
Electronic Patient Monitoring: Pulse oximeter
Placed on a finger, toe, or earlobe, where it continuously monitors both pulse rate and blood oxygen levels (oxygen saturation of hemoglobin)
