FINAL EXAM Flashcards
SBAR
S: Situation; “What is going on right now?”; pt name, unit, room #
B: Background; “What are the circumstances leading to the situation?”; admission date/diagnosis, allergies, baseline VS/assessment, code status, meds, labs
A: Assessment; “What is you assessment of the problem?”; focused subjective & objective system assessments, impression
R: Recommendation; “What is your recommendation?”; order change, referral, provider visit
R: Read back, restatement
Normal VS
BP: systolic less than 120, diastolic less than 80; hypertension is greater than or equal to 140/90 HR: 60-100 bpm RR: 12-20 breaths/min Temperature: 97-99 O2: >90%
What is considered a fever?
> 100.4; increased HR, RR, thirst
What do you need to note regarding pulse?
- rate, rhythm, quality, bilateral equality
- absent=0, normal=2+, bounding=4+
- tachycardia: >100 bpm
- bradycardia: <60 bpm
When would you check the apical pulse?
If pulse is irregular, if pt has cardiac history, in infants and children. Located at 5th. intercostal space, mid clavicular line, count for 60 seconds.
What defines apnea?
Absence of breath for 15 seconds.
What is the heart doing with systole? Diastole?
- Systole: ventricle contraction
- Diastole: ventricle rest/filling
What causes HYPERtension?
Hypertension is defined as a systolic reading >120. Causes decreased blood flow to the organs, thickening of artery walls and loss of elasticity.
What causes HYPOtension?
Defined as <100/60 OR 20-30mmHg below patient baseline. Leads to increased HR as the body is compensating.
What defines orthostatic hypotension? What are some educational points?
20mmHg drop in systolic, 10mmHg drop in diastolic. Measure by laying still for 10 minutes, take BP, move to sitting, wait 2 minutes, take BP, move to standing, wait 2 minutes, take BP. Dangling and changing positions slowly for teaching.
Define OLDCARTS.
For history of present illness/ present state of health, use OLDCARTS:
- O: ONSET
- L: LOCATION
- D: DURATION
- C: CHARACTERISTICS (quality)
- A: AGGRAVATING/ALLEVIATING FX
- R: RELATED SYMPTOMS
- T: TREATMENT
- S: SEVERITY (pain scales and goals)
Define ROS.
- ROS: Review of systems; subjective head-to-toe evaluation of past and present state of each body system; information is given by patient.
- Ask about signs, symptoms,, diseases related to each body system.
- Evaluate health promotion practices.
- Presence or absence of symptoms.
- Psychosocial: BATHE assessment; screening test for anxiety, depression, situational stress disorders.
Define the BATHE assessment.
- B: Background; “What is going on in your life?”
- A: Affect; “How do you feel about it?”
- T: Trouble; “What troubles you the most about the situation?”
- H: Handle; “What helps you handle the situation?”, “Do you have the resources?”
- E: Empathy; “That must be very difficult.”, acknowledge the difficulty of the stressor
Define General Survey.
- The general survey is the global impression of the person.
- Use all senses to assess the patient:
- Physical appearance: age, sexual development, LOC, skin color, facial features
- Body structure/deformities: stature, weight, posture, symmetry, body build, deformities
- Mobility: ROM + gait (smooth, symmetric)
- Behavior: mood (emotional state), affect (expression of that emotion), facial expression, dress, speech, hygiene
What are the general assessment categories and major considerations for neuro?
- Chief compliant, patient’s physical condition, ability to cooperate with assessment; might not be cognitively aware and musculoskeletal can help us with that.
- Issues with brain, spinal cord, and nervous system are early sign of changes, disease, and injury.
Define dysarthria, dysphasia, and ataxia.
-Difficulty speaking, difficulty swallowing, defective muscular coordination due to cerebellar dysfunction.
Compare decerebrate and decorticate posture.
- Decerebrate: deep tendon reflexes exaggerated; pronated palms, clenched teeth; MORE SERIOUS.
- Decorticate: hands come to the core; clenched fists, legs adducted (toes pointing toward each other)
Regarding memory, which type do individuals lose LAST?
**Remote: months or years ago.
Other types: immediate (minutes), recent (earlier in day)
Define paresis.
Partial or complete paralysis; cannot move.
Define paresthesia.
Could signify a nerve injury; burning or tingling feeling.
Define proprioception.
Being aware of where we are (proprioceptors).
Describe orientation assessment.
- Orientation: x 0-4 – assessing level of awareness of reality
- ->Person: own name, occupation
- ->Place: where are you?
- ->Time: day of week, month, year, season (start with most specific level and move to vague)
- ->Situation: why are you here? what brought you in today?
Describe LOC.
LOC: (LEVEL of consciousness) – includes orientation but also includes responsiveness
- ->Fully conscious: awake/alert (x4)
- ->Lethargy: drowsy but awakens, sluggish, needs engagement to stay awake
- ->Obtunded: difficult to arouse, constantly going back out, needs constant stimulation; confused when awake
- ->Stupor: arouses to vigorous and continuous stimulation (usually requires pain); won’t usually verbalize or follow commands
- ->Coma: no purposeful response to anything you do to them
- *more accurate to document signs and observations rather than these labels**
