Week 2 Exam 1 Physical Assess Flashcards
Communication should be…
be asked in the client’s preferred language. All patients have the right to have an interpreter.
-by patients name
Avoid medical jargon.
Avoid certain phrases and leading questions. Ex. “You’re not in pain, are you?”
Ask intimate and personal questions towards the end of the assessment.
Avoid closed-ended questions when looking for details. F
Nurses do not tell patients what to do. They ask how they feel about doing things.
Communication should be
therapeutic
communication should not include
leading and closed ended questions
Consider the age of your patient…
infants, toddler, school age, adult…give choices, show praise, let them touch the tools if allowed
Older adults have more
S = Sleep Disorders
P = Problems with eating or feeding
I = Incontinence
C = Confusion
E = Evidence of falls
S = Skin breakdown
What is included in the assessment?
Biographical data – name, dob, (address and phone number on admission)
Chief complaint/History of present illness
Past medical history
Review of systems
Family history
Lifestyle – s
Occupation – who fought in Vietnam – agent orange
Insurance –
Social data –
psychological data
What is included in past medical history that is important?
Allergy information
Benefit outweigh the risk
Assessment is what?
Systematic and continuous. Explore complaint, evaluate and goal. Prove our. problem by colllecting data
Types of Assessment
Initial/Comprehensive assessment:
An initial (head to toe) assessment includes a health history.
- Ongoing partial assessment or focused assessment
- Emergency assessment
- Special needs assessment
What kind of assessment would the nurse perform after the client returns from xray? Ongoing assessment
What are the two types of data?
Subjective (what someone says) and objective ( which is measurable).
Look at trends when it comes to vital signs.
What are normal vital signs?
Temperature
97.5-99.5 101.5 is temp for hospital
Heart Rate
60-100 bpm
Respirations
12-20
Blood Pressure
<120/80 mmHg
Oxygen Saturation
95-100%
Pain Scale
0 (0-10)
When to assess vitals? Select all that apply
-On admission
-According to hospital policy/procedure (q4 or q8hours)
-Change in condition
-Before and after surgery or invasive procedures
-Before and after administering meds that affect cardiovascular/respiratory function
-Special situations – blood products, sedation
-At discharge
What is different about axillary temperature?
Add 1 degree
Example: temp of 101.5
with axillary it will be 102.5
When do we not treat temperature?
When it is less than 101.5
What assessment findings would indicate dehydration?
No urination
Hyperthermia
Body temp above 103 degrees
Hypothermia
Body temp less than 95
What is normal Heart Rate
Normal 60-100
-Bradycardia <60
-Tachycardia >100
-Apical heart rate is used to determine pulse. It is the point of maximum impulse (PMI).
It is located midclavicular at 5th intercostal space. Most accurate.
Know the assessment points on the heart.
Slide 26 on physical assessment lecture
Which of the following findings should be referred to the primary care provider so that an EKG can be ordered? Why?
Patient A who has a regular, radial pulse of 100 bpm, equal bilaterally.
Patient B who has regular apical pulse of 100 bpm.
Patient C who has irregular apical pulse of 78 bpm.
Patient D who has a regular apical pulse of 59 bpm.
Answer C
Assessing a pulse
Rate: Times per minute the nurse hears or palpates the pulse.
Rhythm: regularity of pulses – electrical activity of the heart
Strength: amplitude or pulse volume – absent (0), diminished (1+), brisk (2+), increased (3+), and bounding
Equality: impulses should be symmetrical in quality and quantity on both sides of the body at the same location
What affects pulse rate?
Exercise
Dehydration
Fever
Medications-albuterol, levothyroxine, epinephrine, narcotics
Changing position
Pain
Anemia
Hypoxemia
Stress
Smoking, illegal drugs, alcohol
Treat abnormal heart rate
Treat the CAUSE
Client Y’s pulse is 50 and they complain of pain ofa level 3 of 10. Client Y asks if they can have their narcotic pain medication. The proper response by the nurse is:
Sure, I will be back shortly.
No, your heart rate is too low.
How about some Tylenol?
No, your pain level has to be 4 to receive narcotics.
Answer C.
Bradypea is a rate less than?
12 breaths per min
Tachypea is greater than ? Breaths per min..
20
What triggers the respiratory center?
Rising carbon dioxide
Respiratory Complications
What is Cheyne-Strokes?
IIrregular rate and depth that follow a cyclical pattern slow rate, faster, normal, slow again, faster, normal…ends with apnea – associated with death
What is Kussmauls?
Increased respiratory rate, but regular in pattern – associated with acidosis
When does hypoventilation happen?
Examples COPD, sedation
A nurse is reviewing the vital signs for a client who was admitted with shortness of breath. The nurse notes the client’s respiratory rate is 24/min. The nurse should use which of the following terms when documenting this finding?
Hypoventilation
Apnea
Tachypnea
Cheyne-stokes respirations
Labored
Answer C
Normal pulse ox?
95% and up
hypoxia less than 90%
Blood pressure
Normal 120/80
Hypotension 90/60
Hypotension- caused from illness, dehydration, low fluid volume
Hypertension is above 130
caused from vascular resistance, fluid overload, heart failure, poor kidney function
The nurse is caring for a client with a BP of 90/60. What is the first intervention the nurse could perform?
Reassess the patient. Then lay them down, feet above head so blood to return to the heart
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take first?
a .Request a prescription for an antihypertensive medication.
B. Ask the client is they are having pain.
C. Request a prescription for an antianxiety medication.
D. Return in 30 min to recheck the client’s blood pressure.
answer b.
Which of the following is an unexpected assessment finding in a 40 year-old?
a. Brisk pulse strength of 2+
b. Equal time space between each pulsation
c. Pulse rate of 95 bpm
d. Stronger radial pulse on left compared to right
answer D
A nurse is measuring the oxygen saturation of a client who has cyanosis of the extremities. Using a pulse ox, where does the nurse place the sensor probe? Select all that apply.
Forefinger
Thumb
Forehead
Bridge of nose
Earlobe
Great toe
C,D, AND E. (double check)
A nurse is obtaining a client’s vital signs. The client has a new onset temp of 102° F. Which of the following vital signs would accompany this finding?
An elevated pulse rate
A decreased blood pressure
An elevated blood pressure
A decreased pulse rate
Answer A
Eyes should be what?
Pupils are Equal, Round, Reactive to light, and Accommodate (PERRLA)
The nurse is caring for a patient admitted with heart failure. Initial vital signs are:
BP: 155/90
HR: 110
RR: 30
O2 Sat: 86%
Temp: 99.1 F
What is the nurse’s priority? Why? The patient’s admission diagnosis is heart failure. How is the diagnosis related to the assessment findings?
Is heart failure chronic or acute?
What orders would the nurse expect?
Oxygen- need to breath. Possible heart failure. Hear failure is chronic. Orders- diacritics, oxygen, breathing treatment
Assessment process (3 STEPS)
- inspection
- Auscultation
- Palpation
What is the EMV/Glasgow coma scale?
Determine the coma scale of a patient.
Lungs are listened to..
Side to side to compare them
Lung sounds
-Diminished Lung sounds-can hear air enter and leave the lungs
-Wheezes-Diminished in the bases – limited air movement
-Rhonchi- high pitched, usually heard on expiration, can often be heard without stethoscope, caused by narrowing airways
-Crackles-caused by fluid in the alveoli, bubbling, wet sound, doesn’t clear with cough
-Stridor- piercing, high pitched, audible without stethoscope, EMERGENCY, obstruction
Can rhonchi be cleared with cough?
yes
Can crackles clear with cough?
no
Pulses (Rate on scale)
0 = absent, impalpable
+1 = weak, thready, diminished
+2 = normal, brisk
+3 = increased, strong
+4 = bounding, full volume
NEVER PALPATE BOTH CAROTID ARTERIES AT THE SAME TIME.
Do not document absent bowel sounds without listening for how long?
5 mintues
How much is normal urine output?
30 mL per hour.
Morse Fall Scale is used for what?
Fall Risk
