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1002 > Week 12 revision questions > Flashcards

Week 12 revision questions Flashcards

1
Q

What are we finding out during a physical assessment?

A

What’s going on and what does this mean?

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2
Q

What kind of data do we get in a physical assessment?

A

Subjective and objective data

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3
Q

What techniques are included in a physical assessment?

A

> Inspection
Auscultation
Palpitation
Percussion

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4
Q

What is in the primary assessment?

A

> A-G assessment (structured and systematic)

>Allows for identification of immediate threats to health

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5
Q

What is a focused assessment?

A

Focuses on a specific body system relating to the presenting problem/concern.

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6
Q

What are our main physical assessments?

A 
>Respiratory
>Cardiovascular
>Thermoregulation
>Fluid balance
>Neurological
>Neurovascular
>Mental health (MSE)
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7
Q

What do we do in a focused assessment for cardiovascular?

A

> ECG
Auscultation of the apical heartbeat (quality and rate).
Palpate the pulse - we are feeling for a strong and regular pulse.
Take a blood pressure - how is the heart working as a pump?
Assess central and peripheral circulation

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8
Q

Explain the process of basic life support

A 
D - danger
R - responsiveness
S - send for help
A - airway 
B - breathing
C - CPR
D - defibrillation
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9
Q

What might affect an oximeter reading?

A

> Nailpolish
Not calibrated
Not on the finger properly
Taking blood pressure on the same arm

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10
Q

What might affect a blood pressure reading?

A

> Cuff in the wrong position
Prior exertion
Not giving 1-minute rest

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11
Q

What might affect an ECG reading?

A

> Metal jewellery etc. can affect the reading as it disturbs electricity.
Moving or taking
Leads not being on properly

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12
Q

What do we do for a focused assessment for neurological?

A

GCS - checks for consciousness by assessing:
>Best eye opening response (PEARL)
>best verbal response
>Best motor response

the highest score is 15 and the lowest is 3

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13
Q

What do we do for a focused assessment for neurovascular?

A

Assessment of the peripheral circulation and the nerves.

> Assess the colour, temperature and warmth of the peripherals
Assess cap refill (should be less than 3 seconds)
Assess the peripheral pulses to make sure body parts are getting blood supply
Assess sensation, motor function and pain
Do the 6 P’s
Compare each side

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14
Q

What do you do if observations are outside of normal ranges?

A

Call for a clinical review (30 minutes).

While you’re waiting for the team to arrive, stay with the patient, reassure them and continue monitoring closely.

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15
Q

What is the normal range for GCS?

A

15.

A drop of 1 is a clinical review (yellow).
A drop of 2 is a rapid response (red).

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16
Q

How does the body response to hypothermia?

A

Increased heart rate due to constricted blood vessels. The blood vessels constrict to draw blood to the centre of the body where the vital organs are.

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17
Q

How does the body respond to hyperthermia?

A

Diaphorsis (sweating) to try to cool the body down.

Vasodilation to deliver more blood to the surface of the skin.

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18
Q

What does a pain assessment consist of?

A

P - precipitating factors (what were you doing when it started? What makes it worse?)
Q - quality of pain
R - a region of pain/does it radiate?
S - severity from 0-10
T - timing (how long has it been going on?)

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19
Q

What is the systematic approach to health assessment?

A
  1. Adult health assessment
  2. Primary assessment (A-G)

If there is an emergency:

  1. Brief history
  2. Focused assessment

If there is no emergency:

  1. Thorough history
  2. Full assessment
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20
Q

What do you do if a patient is unresponsive?

A

Call for a rapid response (15 minutes).
Make note of the time.
DRSABCD.

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21
Q

How do we assess the conduction of the heart?

A

ECG

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22
Q

When would we do an ECG?

A 
>Chest pain
>New admission
>History of chest problems
>Pre-surgery
>Aged patients
>Pneumothorax
>Tachycardia
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23
Q

What affect blood flow?

A

Pressure
Resistance
Neural control of total peripheral resistance

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24
Q

When do we do a pain assessment?

A

> If a patient complains of pain
30 minutes after giving analgesics
Before and after an intervention

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25
Q

What is compartment syndrome?

A

A surgical emergency that requires clinical review!!

It happens when increased pressure within a muscle compartment becomes so great that it pushes on the blood vessels and nerves and cuts off circulation to the limb extremity or puts so much pressure on the nerve that it causes intense pain. when this pain goes away, the nerve has died.

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26
Q

What are the signs of compartment syndrome?

A

The 6 P’s:
Pain - not relieved by simple analgesics. excessive pain on passive flexion and extension. Remember that narcotics can mask the pain from compartment syndrome.

Paresthesia - abnormal tingling in the extremity

Pressure - skin is tight and shiny, pressure in the muscle compartment is higher than 40mmHg (measured by inserting a probe)

Pallor - is a late sign indicating arterial injury

Paralysis - a late sign caused by prolonged nerve compression or muscle damage

Pulselessness - can indicate the death of tissue, check the general colour of the extremity.

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27
Q

Why do we do the assessment?

A

To detect early deterioration.

Physical assessment allows us to collect objective data.

To confirm and identify patient problems

Provides a baseline for the patient (used as a comparison for future findings)

To determine the response to interventions

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28
Q

What is negative balance?

A

Expelling too much fluid.

The patient will be dehydrated.

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29
Q

What is a positive balance?

A

Retention of fluid.

Patient will be overhydrated.

30
Q

What is homeostasis?

A

The maintenance of balance within the body

31
Q

How do we assess hydration?

A

> Input and output (fluid balance chart)
Skin turgor
Mucous membranes

32
Q

When and how do we perform a mental state assessment?

A

> History of mental illness
Presenting to the hospital due to mental health concerns.

We do this using the MSE which observes:
>appearance
>behaviour
>speech
>thought content
>thought form
>perception
>mood/affect
>cognition
>insight/judgement
>risk
33
Q

What is in a secondary assessment?

A

> Head to toe assessment

>Body systems assessment

34
Q

What is reliability?

A

If you perform the same measurement again, will it give you the same reading?

35
Q

What is validity?

A

If you do the measurement manually, will you get the same reading as the machine?

36
Q

What are the normal ranges for each vital sign (RR, O2, BP, HR, DIS, TEMP, PAIN)?

A 
RR - 12-20
O2 - 95-100%
HR - 60-100
DIS - alert
TEMP - 36.1-37.1
Pain - 0
37
Q

Understand the cardiac cycle

A
  1. Atrial systole
  2. Isovolumetric ventricular contraction
  3. Ejection
  4. Isovolumetric ventricular relaxation
  5. Passive ventricular filling
38
Q

How does blood flow through the heart?

A
  1. Deoxygenated blood from the body enters the right atrium through the inferior and superior vena cava.
  2. It passes the tricuspid valve and enters the right ventricle.
  3. It passes the pulmonary valve and enters the lung via the pulmonary artery.
  4. Oxygenated blood enters the left atrium via the pulmonary veins.
  5. It passes the mitral valve and enters the left ventricle.
  6. It passes the aortic valve before it is pumped to the body through the aorta.
39
Q

Understand the cardiac electricity pathway

A
  1. Impulse generated in the SA node
  2. The impulse travels to both atria, stimulating them to contract
  3. The AV node (makes sure the atria contract first) receives a signal from the SA node and passes it to the AV bundle/bundle of his.
  4. The signal spreads down the left and right bundle branches before turning up at the apex and distributing it along the purkinje fibres, causing the ventricles to contract.
40
Q

What affects cardiac performance?

A

Myocardial contractility - the ability of the heart to increase the force of contraction. The higher the contractility, the higher the stroke volume.

Cardiac output - the volume of blood flowing through either the systemic or pulmonary cycle. Cardiac output = stroke volume x heart rate.

41
Q

What instructions do we give a patient before we do an ECG?

A

> Explain what an ECG is and why you’re doing it.
Reassure them that it won’t hurt
Ask them to lay still and not talk
Ask them to take any metal off as it may interfere with readings

42
Q

What are some factors that might affect blood flow?

A

> Pressure

> Resistance - changes in diameter of blood vessels.

> Neural control of peripheral resistance - barorecepters can sense pressure changes and adjust blood pressure. Vasoconstriction and vasodilation.

43
Q

Where does pain go on the A-G assessment?

A

D for disability

44
Q

What does the A-G assessment include?

A 
A - airway
B - breathing
C - circulation
D - disability
E - exposure
F - fluids in and out
G - glucose
45
Q

How is temperature regulated?

A

Temperature is regulated by the hypothalamus which checks our temperature and compares it to our average temperature before sending messages out to change the way our body is working if it needs to.

46
Q

How do you assess the respiratory system?

A

Inspection - spine should be in a straight line, shoulders back, symmetrical intercostal spaces, no clubbing of the fingers, no paradoxical breathing, no use of accessory muscles or abdominal breathing, straight trachea. Look for sweating, facial expression, foreign objects, swelling, burns, tumors, skin colour and condition.

Palpitation - palpate the entire chest wall. Make sure the trachea is straight, no tenderness, skin colour, temperature and moisture are all good, any lumps or masses, palpate for emphysema (feels like rice bubbles), feel for symmetry during breathing.

Percussion - Percuss at 5cm intervals, comparing sides. A dull sound is a solid structure, a drum sounds is air.

Auscultation - Listen to the front and back of the chest. Wet, noisy, stridor and wheezy sounds are nor normal.

47
Q

What might affect the delivery of oxygenated blood?

A

> Haemoglobin adequacy
Peripheral vascular resistance
Cardiac output
haemoglobin concentration

48
Q

What is pulmonary oedema?

A

A condition caused by excess fluid in the lungs.

49
Q

Where are the pulse sites in the body?

A 
>Temporal artery (temple)
>Carotid artery (neck)
>Apical pulse (chest)
>Brachial pulse (elbow)
>Radial pulse (thumb)
>Femoral pulse (groin)
>Popliteal artery (back of knee)
>posterior tibeal artery (inside ankle)
>Pedal pulse (top of foot)
50
Q

What is a Glasgow Coma Scale?

A

A standardised and objective approach to measuring level of consciousness.

If staff are not trained to use this scale, it is not reliable.

The score can be used to measure a trend for neurological dysfunction and determine a basis for clinical management.

51
Q

What health problems may lead to an acid/base imbalance?

A

> Diabetes mellitus
COPD
Kidney disease

52
Q

How do we assess pH (acid/base balance)?

A

> Blood test

>Urinalysis

53
Q

What do fluid balance charts do?

A

Calculate the input and output of fluids in and out of the body.

54
Q

What can a urinalysis tell us?

A

Specific gravity - the concentration of particles in urine. (is it concentrated or diluted?).

Presence of bilirubin - tests liver function.

Presence of blood - indicates trauma/infection.

Presence of leukocytes - indicates infection.

Presence of nitrides - produced by bacteria, indicates UTI.

pH - should be between 4.5-8.0

Presence of proteins - muscle cells breaking down

Presence of glucose - Indicative of diabetes

Presence of keytones - indicative of weight loss/fasting or diabetes.

55
Q

What is subjective data?

A

Data that the patient or their family tells you - influenced by their feelings or opinions.

56
Q

What is objective data?

A

Numbers and statistics that you gets from tests.

57
Q

What are some communication techniques we can use?

A 
>Choose the right time
>Create a conductive environment
>Use positive body language
>Seek cooperation
>Use good communication techniques - listening, asking questions, validation
>Sit across from them
>Be organised
>Document
OARS:
O - open ended questions
A - affirmation
R - reflection/repetition
S - summarise key points
58
Q

What are the zones of personal space?

A

Intimate zone - 0-45cm

Personal zone - 45cm-1.2m

59
Q

What are the zones of touch?

A

Social zone - hands, arms, shoulders, back (permission not needed)

Consent zone - mouth, wrists, feet (permission needed)

Vulnerable zone - face, neck, front of body (special care needed)

Intimate zone - genitals (great sensitivity needed)

60
Q

How do you assess the cardiovascular system?

A

Inspection - skin colour and temp

Palpitation - skin, cap refill distal pulses, oedema, calves for tenderness

Auscultation - heart sounds

61
Q

How do you assess the gastrointestinal system?

A

Inspection - abdomen

Palpitation - the abdomen starting from where it hurts and moving closer

Auscultate - bowel sounds

Assess bowel movements

62
Q

How do we assess nutrition?

A

Inspection - oral cavity

Assess ability to swallow, BGL, weight, BMI

Estimate amount of meals eaten.

63
Q

How do we assess the renal system?

A

Palpitation - bladder

24 hour fluid balance chart, daily weight, assess urine output, urinalysis

64
Q

How do we assess the integumentary system?

A

Inspection - skin integrity, wounds, dressings, invasive lines

Palpitation - skin to see if it blanches.

65
Q

How do we assess the musculoskeletal system?

A

Inspection - major joints

Observe - gait, ability to transfer and mobilise

66
Q

What tests can we perform for lung function?

A

> Spirometry

67
Q

What tests can we perform to assess oxygenation?

A

Arterial blood gasses (PaO2) measures the amount of O2 dissolved in plasma (80-100mmHg)

PaCO2 is the partial pressure of CO2 in blood (35-45mmHg)

Pulse oximetry - provides continuous assessment of SpO2 (how oxygenated the haemoglobin is).

68
Q

What might affect blood pressure?

A 
>CO
>Vascular resistance
>Volume of circulating blood
>Viscosity
>Elasticity of the blood vessels
69
Q

What might cause inaccuracies when taking temperature?

A

> Environment
User error
Patient phenomena
Instrumental inaccuracy (calibration)

70
Q

What are the causes for loss of conciousness?

A 
A - alcohol
E - epilepsy
I - insulin
O - overdose
U - uraemia (nitrogenous waste buildup due to renal failure)

T - temperature/trauma
I - infection
P - psychogenic (no physical or biological reason)
S - septicaemia/surgery

other causes include - shock

71
Q

When do we assess GCS?

A 
After:
>Potential head injury
>Seizure
>Unwitnessed fall
>Neurological surgery
72
Q

What is the most important part of the brain?

A

The brainstem controls:
>Consciousness
>Breathing
>Heart rate

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