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Patient Assessment Kettering > General Patient Assessment > Flashcards

General Patient Assessment Flashcards

(79 cards)

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1
Q

Medication reconciliation

A

Ensuring a patient’s medication is as accurate and up to date as possible.

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2
Q

Medication Reconciliation time frame

A

Within 24 hours of admission to hospital

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3
Q

Lethargic,somnolent, sleepy patient

A

Consider sleep apnea or excessive O2 therapy in a COPD patient

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4
Q

Assessing the emotional state of a pt, what would be seen with anxiety?

A

watching every movement, respiratory distress, hypoxemia

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5
Q

Assessing emotional state, Panic

A

Severe hypoxemia, tension pneumothorax, status asthmaticus

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6
Q

6 Activities of daily living

A
  1. bathing with a sponge, bath, or shower
  2. eating
  3. Dressing
  4. Toilet Use
  5. Transferring.
  6. Urine and bowel continence
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7
Q

Assessing activities of daily living can be used to determine?

A
  1. Nursing home admission 2. need for home care providers 3. use of hospital services 4. living arrangments 5. use of physician services 6. insurance coverage 7. mortality
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8
Q

Scoring system used to assess activities of daily living?

A

Katz scoring system

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9
Q

Measuring subjective symptoms :

A

orothopnea general malaise dyspnea pain dysphagia

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10
Q

orthopnea

A

shortness of breathe EXCEPT when in an upright position

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11
Q

general malaise

A

feeling run-down, nausea, weakness, fatigue, headache, ELECTROLYTE IMBALANCE.

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12
Q

dyspnea

A

shortness of breath

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13
Q

pain

A

A reaction of a specific nervous tissue

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14
Q

Dysphagia

A

difficulty swallowing

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15
Q

Proper interview techniques

A

1 Ask open-ended questions. 2 communicate using simple language. 3 utilize pictures, diagrams, etc. for illiterate patients. 3 begin to identify the patients major problems

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16
Q

Assessment by inspection

A

what you can see, age, height, weight, nourishment, etc

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17
Q

Peripheral edema

A

presence of excessive fluid in the tissue known as pitting edema

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18
Q

Causes of peripheral edema?

A

Congestive heart failure Renal failure

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19
Q

Ascites

A

Accumulation of blood in the abdomen, generally caused by liver failure

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20
Q

Clubbing of fingers

A

caused by chronic hypoxemia, suggestive of pulmonary disease such as COPD. The thumb and first finger are affected

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21
Q

Venous distension

A

JVD, (jugular venous distention) Seen during exhalation in patients with obstructive lung disease and air trapping

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22
Q

Capillary refill

A

Indication of peripheral circulation Color should return in 3 seconds

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23
Q

Diaphoresis

A

.A state of profuse heavy sweating .Heart Failure ( recommend diuretics, positive inotropic agents like Digoxin.) .Fever ,infection ( recommend antibiotics) .Anxiety, nervousness ( recommend sedatives) .Tuberculosis/night sweats ( recommend antitubercular drugs )

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24
Q

Decrease in the color of skin

A

ashen, pallor

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25
causes of decrease in the color of skin
anemia, acute blood loss, vasoconstriction via reducing blood flow
26
assessing skin integrity, look for:
pressure sores and ulcers evaluate skin around tracheotomy stoma
27
assessing chest configuration
straight spine, no leaning forward( kyphosis) or side to side ( scoliosis)
28
kyphosis
leaning forward spine, convex curvature of the spine
29
Scoliosis
Spine in S shape, side to side
30
4 critical life functions, in order of importance in an emergency
1. ventilation 2. oxygenation 3. circulation 4. perfusion
31
Pectus Carinatum
anterior protrusion of the sternum
32
signs vs symptoms Signs:
*_Objective_* information * can be measured * color * pulse * edema * blood pressure ect...
33
signs vs symptoms Symptoms :
Subjective information * things the patient must tell you * dyspnea * pain * nausea * muscle weakness etc ...
34
Types of advanced directives
* **DNR** ( Do not resuscitate) pt does not want cardiopulmonary resuscitation * **DNI** ( Do not intubate) pt does not want to be intubated * **Living Will**, describes what pt would want if they become critically ill * **Durable Power Of attorney**, legal document that names a person or agent responsible for making decisions on behalf of the pt
35
36
Pectus Excavatum
Depression of part of the entire sternum
37
Kyphoscoliosis
A combination of scoliosis and kyphosis
38
Barrell chest
increase in A-P diameter
39
Symmetrical chest movement
Both sides move equal at the same time
40
asymmetrical chest movement
unequal movement. May indicate * post lung resection, post pneumonectomy * Atelectasis * Pneumothorax * Flail chest- Paradoxical movement * an endotracheal tube inserted in right or left mainstem bronchi
41
Eupnea Breathing pattern
Normal rate, depth, and rhythm
42
Tachypnea causes
* hypoxia * fever * pain * CNS problem
43
Bradypnea (oligopnea) causes
* sleep * drugs * alcohol * metabolic disorders
44
hyperpnea
increased respiratory rate, increased depth, regular rhythm
45
hyperpnea causes
metabolic disorders/ CNS disorders
46
Cheyne Stokes breathing
Gradually increasing then decreasing rate and depth in a cycle lasting 30-180 seconds, with periods of apnea lasting up to 60 seconds
47
Cheyne Stokes Breathing causes
* increased intracranial pressure * brainstem injury * drug overdose
48
Biot's breathing
Increased respiratory rate and depth, with regular periods of apnea. Each breath has the same depth
49
Biot's Breathing Causes
CNS problem
50
Kussmaul's Breathing
Increased respiratory rate ( usually over 20 bpm), increased depth, irregular rhythm breathing sounds labored. **This can be caused by diabetic ketoacidosis**
51
Kussmaul's Breathing causes
* Hypoxemia * metabolic acidosis * renal failure * **diabetic ketoacidosis**
52
Apneustic Breathing
Prolonged gasping inspiration followed by extremely short, insufficient expiration.
53
Apneustic Breathing causes
* Problem with respiratory center * trauma * tumor
54
Hypopnea
Shallow or slow breathing
55
Accessory muscles of ventilation
* internal intercostal * scalene * sternocleidomastoid * pectoralis major * Abdominal muscles( oblique, rectus abdominus)
56
Assessment of airway patency
* tracheal shift/deviation * enlarged thyroid * short receding mandible * enlarged tongue * bull neck * limited range of motion of the neck or cervical spine
57
mallampati class 1
* soft pallet * uvula * fauces * pillars visable
58
Mallampati Class 2
* soft palate * uvula * fauces visable
59
Mallimpati Score 3
* Soft Palate * base of uvula visable
60
Mallimpati Score 4
Hard palate only visible
61
What Mallampati scores are considered difficult airways?
* Class 1 and class 2 * use fiberoptic bronchoscope or a video-assisted device
62
Assessment by palpation tachycardia \> 100 bpm indicates?
* hypoxemia * anxiety * stress * **Recommend oxygen therapy**
63
Assessment by palpation Bradycardia \< 60 bpm indicates?
* Heart failure * shock * code/emergency * **Recommend Atropine**
64
How much change in heart rate shows adverse reaction?
\> 20bpm
65
paradoxical pulse/pulsus paradoxus
pulse/blood pressure varies with respiration _May indicate_ * Severe air trapping * status asthmaticus * tension pneumothorax * cardiac tamponade
66
Tactile fremitus
vibrations that are felt by the hand on the chest wall
67
Crepitus
Bubbles of air under the skin that can be palpated and indicates the presence of subcutaneous emphysema
68
chest motion symmetry
using both hands and placing them on the pts chest, noting the distance the hands move on patient inspiration. If one hand moves more than the other this is asymmetrical chest rise, and could be **atelectasis** or **pneumothorax**
69
Percussion sounds Resonant
Normal air-filled lungs, gives a hollow sound
70
Percussion sounds Flat
normally heard over the sternum, muscle, or areas of atelectasis
71
Percussion sounds Dull
Normally heard over fluid-filled organs such as the heart or liver. **Pleural effusion** or **pneumonia** will cause this **thudding sound**
72
Percussion Sounds Tympanic
Normally heard over **air-filled** stomach, a drum-like sound and indicates **increased volume** when heard over the lungs
73
Percussion Sounds Hyperresonant
**Booming sound** that can be heard in an area of the lung where either a **pneumothorax** or **emphysema** may be present
74
75
Auscultation Bilateral Vesicular sounds
Normal sounds in both lungs
76
Auscultation Bronchial Breath Sounds
* Normal sounds heard over the trachea or bronchi. * these sounds heard over the lung periphery would indicate lung consolidation
77
Auscultation Technique **Egophony**
The patient is instructed to say "e" and it sounds like an "a". This would indicate consolidation of the lung tissue as with a pneumonia-like condition
78
Broncophony and whispered Pectoriloquy
Terms that refer to increased intensity or transmission of the spoken voice and indicate **consolidation** and **pneumonia**
79

Patient Assessment Kettering (3 decks)

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