Week 1: Assessment Introduction & Foundational Patient Assessments and Techniques Flashcards
3 levels of prevention
Primary, secondary, and tertiary
Primary prevention
A set of actions that aim to prevent disease or injury from occurring.
Ex. Condoms and pre-exposure vaccinations
Secondary prevention
A set of actions that aim to reduce the impact of a disease or injury by detecting and treating it early.
Ex. Screening programs such as mammography to detect breast cancer
Tertiary prevention
A set of actions that aim to reduce the impact of an ongoing illness or injury that has lasting effects.
Ex. For people who have had a stroke: Taking aspirin to prevent a second stroke from occurring
5 steps of the nursing process
Assessment, diagnosis, planning/outcomes, implementation, and evaluations
4 cognitive skills of the assessment process
Clinical thinking, clinical reasoning, clinical judgment, intuitive thinking
Clinical thinking
Purposeful and creative thinking aimed at problem-solving
Clinical reasoning
Identifies abnormal findings, risk factors, and health promotion and prevention behaviors
Clinical judgment
Decisions made based on information available
Intuitive thinking
“Gut feeling”
A patient presents at the ambulatory care clinic for complaints of an upper respiratory infection. While assessing this patient, the nurse needs to identify:
A) Physical assessment findings only
B) Normal from abnormal assessment findings
C) Basic anatomy and physiology
D) Diagnostic value
B) Health assessment is a skill to identify normal from abnormal findings. Nurses need to identify normal and abnormal variants that may indicate the patient has an upper respiratory infection.
What is the federal initiative that is a science-based framework updated every ten years by the U.S. Department of Health and Human Services, which has goals and objectives for health promotion?
A) World Health Organization
B) Healthy People 2030
C) U.S. Preventative Services Task Force
D) Robert Wood Johnson Foundation Initiative
B) Healthy People 2030 identifies health and risk factors for disease and has goals and objectives for health promotion and disease prevention
A 34-year-old patient is about to deliver her first baby. Her husband appears to be supportive but appears worried and nervous. The patient has come to the hospital since her contractions are 8 minutes apart. She has been in labor for 8 hours and has a past medical history of high blood pressure. She states, “I never took prenatal classes and don’t know what to do.” What cognitive skill should you begin to implement?
A) Nursing Process
B) Nursing Assessment
C) Critical Thinking
D) Intuitive Thinking
C) Critical thinking is a problem-solving, reflective process that uses a process of purposeful and creative thinking about resolving problems.
A patient was recently diagnosed with type 1 diabetes and needs teaching about the importance of skin and foot care. This is an example of what level of health prevention?
A) Primary
B) Secondary
C) Tertiary
D) None of the above
C) Tertiary prevention encompasses the restoration of health after illness or disease has occurred. Skin care and foot care help prevent complications of diabetes.
4 objective assessment techniques
Inspection, auscultation, percussion, and palpation
Assessment order
Inspection -> palpation -> percussion -> auscultation
Inspection
To look and assess the physical aspects of the body, posture, appearance, and behavior
Inspection: 5 requirements
Comfortable room temperature, good natural lighting, PPE if necessary, draping to maintain modesty, and compare symmetry of body parts from left to right
Inspection: 7 characteristics assessed
Location, size, color, pattern, shape, odors, and symmetry
Palpation
Using the fingers and hands to assess
Palpation: Hand parts and purposes
Finger pads: Fine assessment, skin texture, shape, pulse, crepitus.
Dorsal (back) hand: Assess temperature.
Ulnar surface (ball) of the hand: Assess vibration, fremitus, thrills
Palpation: Equipment
Gloves, additional PPE (if needed)
Light palpation: Purpose
Feel for surface characteristics
Deep palpation: Purpose
Feel for deeper characteristics such as organs
Percussion
Tapping body parts
Percussion: Equipment
Gloves, additional PPE (if needed)
Percussion: 3 types
Direct, indirect, and indirect fist (blunt)
Direct percussion: Purposes (2)
Assess size, consistency, and boarders of body organs and presence/absence of fluid
Direct percussion: Technique
Lightly tap with 1-2 fingertips on the area to be percussed
Direct percussion: Sound characteristics (4)
Frequency (pitch): high, low, dull. Intensity: soft (solid tissue), moderate (fluid-filled), loud (air-filled). Duration: length of time sound is heard. Quality: what does it sound like
Indirect percussion: Technique
Lay the middle finger of the nondominant hand on the area to be assessed. Short and sharp taps with the middle finger of the dominant hand on the non-dominant hand
As the density of the underlying structure increases, the percussion sounds become (softer/louder)
Softer
5 specific percussion sounds
Tymphany, dull/thud-like, resonance, hyper resonance, and flatness
Percussion sounds: Tympany (Intensity, pitch, quality, structures)
Intensity: Loud.
Pitch: High.
Quality: Drumlike.
Structures: Air-filled structures, typically abdominal areas
Percussion sounds: Dull/thud-like (Intensity, pitch, quality, structures)
Intensity: Soft to moderate.
Pitch: Medium.
Quality: Thud-like.
Structures: Solid organs, fluid collection, or areas of consolidation such as a tumor or mass
Percussion sounds: Resonance (Intensity, pitch, quality, structures)
Intensity: Moderate to loud.
Pitch: Low.
Quality: Hollow.
Structures: Normal lungs
Percussion sounds: Hyperresonance (Intensity, pitch, quality, structures)
Intensity: Very loud.
Pitch: Low.
Quality: Booming.
Structures: Over air-filled spaces such as hyperinflated lungs
Percussion sounds: Flatness (Intensity, pitch, quality, structures)
Intensity: Soft.
Pitch: High.
Quality: Dull.
Structures: Areas of increased density such as muscle, bone, joints, and solid masses
Indirect fist percussion: Purpose
To assess organ tenderness
Indirect fist percussion: Technique
Gently lay your nondominant hand over the area to be assessed. Using the ulnar surface of your closed dominant hand, firmly thump the dorsum of the nondominant hand
4 body systems assessed using auscultation
Cardiovascular, respiratory, gastrointestinal, and peripheral vascular
Auscultation: 4 characteristics of sound
Duration, intensity, pitch, and quality
Direct auscultation: Purpose
To listen to and assess sounds produced by the body without a stethoscope (not common)
Indirect auscultation: Purpose
To listen to sounds produced by the body with an amplification device
Indirect auscultation: Equipment
Stethoscope, Doppler, PPE (if needed)
A patient is reporting abdominal discomfort and constipation. The first step just prior to performing an assessment on this patient is to:
A) Put on a disposable gown
B) Wash your hands
C) Stand on the left side
D) Put on gloves
B) Always wash your hands before and after an assessment preferably in front of the patient. Health assessment requires direct contact with the patient.
Inspection requires the use of the three senses except the sense of:
A) Hearing
B) Seeing
C) Smelling
D) Feeling
D) You do not feel the patient when you are looking at and inspecting the patient.
The patient states that he has a lump under his upper right arm. What part of the hand is best to use to assess the lump?
A) Dorsal surface
B) Finger pads
C) Ulnar surface
D) Anterior surface
B) Finger pads assess fine discrimination and sensations on the surface areas such as texture, shape, consistency, pulses, and crepitus (popping sounds under the skin).
What percussion sound will be heard over increased tissue density such as bones?
A) Tympany
B) Dullness
C) Resonance
D) Flatness
D) Flatness is heard over increased tissue density such as bones
A patient comes to the urgent care clinic stating that his left eye feels “gritty.” The nurses puts on gloves and gently pulls down the lower lid to assess the eye. What technique is the nurse using?
A) Palpation
B) Indirect Inspection
C) Direct Inspection
D) Percussion
B) Direct inspection is carefully visualizing and inspecting a specific area. Indirect inspection is using specific equipment to improve visualization of an area such as an ophthalmoscope to look at the internal structure of the eye.
5 vital signs
Temperature, pulse rate, respiratory rate, blood pressure, and pain
Sequence of vital sign assessment
Temperature -> pulse -> respiratory rate -> blood pressure
Temperature: Locations (4)
Oral, tympanic (ear), temporal, and rectal
Oral temperature: Normal values
97.5F to 99.5F (36C to 37.5C)
Oral temperature: Hypothermia
<95F
Oral temperature: Hyperthermia
> 100F
Pulse: Locations (2)
Radial and apical
Radial pulse: Normal values
60-100 bpm
Radial pulse: Bradycardia
<60 bpm
Radial pulse: Tachycardia
> 100 bpm
Radial pulse: Quality and scale
0 = Absent: Pulse cannot be felt.
1 = Weak/thready: Pulse is barely felt and can be easily obliterated by pressing with the fingers.
2 = Normal quality: Pulse is easily palpated, not weak or bounding.
3 = Bounding or full: Pulse is easily felt with little pressure; not easily obliterated
Respiration rate: Normal values
12-20 breaths per minute
Respiration rate: Characteristics
Depth, rhythm, and effort
Blood pressure: Normal values
<120 mmHg / <80 mmHg
Blood pressure: Locations
Upper arm, forearm, and thigh
Acute pain: Physical changes (8)
Inc. BP, inc. RR, dilated pupils, diaphoretic (sweaty), inc. restlessness, inc. verbal responses (crying, moaning), nausea, and tissue damage/injury
Chronic pain: Physical changes (7)
Normal vital signs, normal pupils, no restlessness, no verbal response, no nausea, dec. functional capacity
Sources of pain: Cutaneous pain
Superficial, sharp pain from skin and SQ tissue
Sources of pain: Colicky pain
Fluctuating, wave-like pain. Usually GI
Sources of pain: Nociceptive pain
Damage or inflammation to the sensory nerves in soft tissue
Sources of pain: Nociceptive, somatic pain
Diffuse, sharp, and well-localized in superficial structures; dull, achy, and diffuse in deep somatic structures
Sources of pain: Nociceptive, visceral pain
Achy, dull, deep, crampy pain typically in the abdominal region
Sources of pain: Neuropathic pain
Damage to PNS or CNS with numbness and tingling
Phantom limb pain
Pain in the perceived missing limb
Psychogenic pain
Pain with no organic or structural cause, mental.
Transmitting pain
When pain travels through nerve transmission to other parts of the body
Transmitting pain: Radiating pain
Starts in one area and spreads out to another part of the body (e.g., toothache that radiates to the ear or head).
Transmitting pain: Referred pain
Felt in an area away from the actual source of the pain (e.g., gallbladder pain may be felt in the shoulder or upper thoracic region of the back)
2 mnemonics to assess pain
OLDCARTS and OPQRST
OLDCARTS attributes
O = Onset.
L = Location.
D = Duration.
C = Character.
A = Aggravating or Alleviating factors.
R = Related symptoms.
T = Treatment.
S = Severity
OPQRST attributes
O = Onset.
P = Provocation and palliates.
Q = Quality.
R = Radiation and region.
S = Severity.
T = Timing or temporal
5 pain scales
Numeric Rating Scale (NRS), Wrong-Baker Faces Pain Rating Scale, Verbal Rating Scale (VRS), CRIES scale, and Iowa Pain Thermometer (IPT)
CRIES scale: Attributes
C = Crying.
R = Requires O2 for SaO2 <95%.
I = Increased vital signs (BP and HR).
E = Expression.
S = Sleepless
CRIES scale: Clinical use
Infants <34 weeks
CRIES scale: Scoring
A score of >4 is notable
3 pain assessment tools
McGill Pain Questionnaire (MPQ), Pain Assessment Tool, and Pain-QuILT
2 pain assessment tools for communicatively impaired patients
Critical Care Pain Observation Tool (CPOT) and Pain Assessment in Advances Dementia (PAINAD) Scale
4 types of pain duration
Acute (short term), chronic (long term), intractable (constant), or intermittent (comes and goes)
Normal values: Oral temperature
97.5F to 99.5F
36C to 37.5C
Tympanic, temporal, and rectal temperature values will always be _____ than oral temperature values
Higher
Normal values: Radial pulse
60-100 bpm
40-60 bpm for athlete
Regular rhythm
Normal values: Respiratory rate
12-20 breaths/min
Even pattern, regular rhythm
Normal values: Blood pressure
<120/<80
