Chapter 13 Flashcards by Jennifer Gonzalez

Essential Skills of Patient Assessment

-Observation
-Evaluation
-Assessment
-Communication
-Relaying information

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AIDET communication too stands for:

-Acknowledge
-Introduce
-Duration
-Explanation
-Thanks

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Warmly greet the patient by name

Acknowledge

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Tell the patient who you are (name, title, length of time in the profession) and what you will be doing for them.

Introduce

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Explain how long the examination will take, and frequently update the patient of any delays

Duration

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Describe the examination the patient will be undergoing. This is the opportunity to collect pertinent history.

Explanation

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Express gratitude to the patient for choosing your facility for his or her care, for exhibiting patience, for being positive throughout the examination, and so forth

Thanks

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Questioning Techniques for Taking a History

Open-ended questions
Facilitation
Silence
Reflection or reiteration
Clarification or probing
Summarization

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What are the elements of a history

-Onset
-Duration/chronology
-Specific location
-Quality of symptoms
-Severity of pain
-What aggravates/alleviates
-Associated manifestations

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Onset sampling questions

How did it start? What happened? When did it first trouble you? Was it sudden or a complaint that gradually got worse?

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Duration/Chronology sampling questions

Have you ever had it before? Has it been continuous? Does it bother you all the time? How long has this attack been bothering you?

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Specific location sampling questions

Where does it hurt (or where is the problem)? Can you put your finger on where it hurts the most? Does it hurt anywhere else?

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Quality of symptoms sampling questions

What does it feel like? Sharp, stabbing pain? Dull ache? Throbbing pain?

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Severity of pain sampling questions

How severe is it? Mild, moderate, or severe? (Some like to use a pain scale of 0 to 5 or 0 to 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?

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What aggravates/alleviates sampling questions

What seems to make it worse? When is it worst? Is it worse after meals? At night? When you walk? 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?

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Associated manifestations sampling questions

Are there any other symptoms that you are experiencing that may be related to your chief complaint?

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Is often the first and primary observer of a significant change in the patient’s current condition

radiographer

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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

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Color code wristband for allergy

red

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Color code wristband for fall risk

yellow

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Color code wristband for DNR

purple

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A patient with a previous history of allergies is sometimes referred to as

allergenic individual

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The most important process in patient assessment is sometimes called

eyeballing the patient

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Physical Apperance and Responses

-Skin color
-Temperature
-Level of consciousness (LOC)
-Breathing

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Denotes a bluish coloration in the skin and indicates a lack of sufficient oxygen in the tissues. This is most easily seen in the mucous membranes, such as the lips or the lining of the mouth.

Cyanotic

Cold sweat

Diaphoretic

Hot, dry skin may indicate a

fever

Can cause cool, moist skin with wet palms and shaking hands

Acute anxiety

What are the 4 levels of consciousness

1. Alert and conscious 2. Drowsy but responsive 3. Unconscious but reactive to painful stimuli 4. Comatose

is a seizure disorder without convulsions that can cause a brief loss of consciousness without warning

Absence (petit mal seizure)

Normal breathing is considered

quiet and calm

A form of chronic obstructive pulmonary disease that prevents patients from exhaling effectively, limiting their capacity for inhaling fresh air

Emphysema

is the term for an inability or serious difficulty in breathing when lying flat

Orthopnea

They involve the measurement of temperature, pulse rate, respiratory rate, and blood pressure

Vital signs

An instrument for indirect measurement of blood pressure. It consists of an inflatable cuff that fits around the arm, a bulb for controlling air pressure within the cuff, and a mercury or aneriod manometer

Sphygmomanometer

Body temperature is lowest in

the morning

Body temperature is the highest in

the evening

Temperatures may be obtained by:

oral, rectal, axillary, tympanic and temporal artery routes

Inserted into external ear canal

Tympanic temperature probe

contain an infrared sensor that measures the temperature over the temporal artery in the region of the forehead. The gentle scan across the forehead and temporal region is easily and quickly accomplished and is not objectionable to patients. Research indicates that this method is more consistently accurate than the tympanic method.

Temporal artery thermometers

Medical term for fever

Pyrexia

Is a sign of increased body metabolism usually in response to an infectious process

Fever

Normal adult temperature range is

97-99 degrees Fahrenheit

Average oral temperature is

98.6 degrees Fahrenheit

Fever is typically considered greater than

100.4 degrees Fahrenheit

the advancing pressure wave in an artery caused by the expulsion of blood when the left ventricle of the heart contracts.

Pulse

The heart rate is measured in

beats per minute (bpm)

The most common site for palpation of the pulse is

The radial artery

Why can't you take a accurate pulse using your thumb

Because your own thumb has a pulse

If the radial pulse is weak or difficult to count you will do (blank) instead

Carotid artery

This pulse may be significant when there is a question of compromise in the peripheral circulation

The dorsalis pedis or pedal pulse

A measurement taken by listening to the heartbeat through a stethoscope placed over the apex of the heart

apical pulse

abnormally rapid pulse occurs when the heart rate is greater than 100 bpm

Tachycardia

Average normal pulse rate in adults

60 bpm and 100 bpm

Heart rate that is too slow; less than 60 bbpm

Bradycardia

Normal range in adults of breaths per minute

12 to 20 breaths/minute

Slow breathing with fewer than 12 breaths/min

Bradypnea

More than 20 breaths/min

Tachypnea

Difficult in breathing

Dyspnea

inflammation of the pleura causing adhesions between the lungs and the chest wall

Pleurisy

Cessation of breathing (stops or restarts)

Apnea

Abnormally high blood pressure

Hypertension

Abnormally low blood pressure

Hypotension

Patients in (blank) exhibit a significant increase in pulse rate and respiratory rate

Shock

Term that means "not wet" or without liquid

aneroid

The top figure is the (blank) pressure and is a measure of the pumping action of the heart muscle itself

systolic pressure

The bottom figure is (blank) pressure and indicates the ability of the arterial system to accept the pulse of blood forced into the system when the left ventricle contracts

diastolic pressure

Normal range for systolic

95 to 119 mm Hg

Normal range for diastolic

60 to 79 mm Hg

Normal range for blood pressure is

120/80 mm Hg

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.

Hypertension

Diastolic pressure <50 mm Hg or systolic pressure <90 mm Hg May also indicate shock

Hypotension

Common Laboratory Tests for Patient Assesssment

Complete Blood Count Erythrocyte Sedimentation Rate Blood-Clotting Assessments Blood-Chemistry Tests

The most common pulse points are

Temporal, Carotid, Apical, Femoral, Brachial, Radial, Popliteal, Posterior tibial, and Dorsalis pedis

fluid loss

Dehydration

A blood clot formed on the wall of a vessel is called

Thrombus

A thrombus formed in a large vessel sometimes detaches from the vessel wall, becoming a free-floating clot

Embolus

Placed on a finger, toe, or earlobe, where it continuously monitors both pulse rate and blood oxygen levels

Pulse oximeter

Normal waveform

Sinus rhythm

One comprehensive way to monitor cardiac activity; provides continuous measurement of heart rate and blood pressure

Arterial catheter

Device that measures the electrical activity of the heart; displays the information graphically in the form of waves on a paper tracing or on a monitor

Electrocardiograph monitor

Device that records or monitors the electrical activity of the brain

Electroencephalography

Chapter 13 Flashcards

(82 cards)