Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

6011 Test 1 > Head to Toe (Lecture 2) > Flashcards

Head to Toe (Lecture 2) Flashcards

1
Q

Hand Hygiene

A

Foam in, Foam out

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

SOAP - Objective

A

Findings you can Observe. Includes:

  • Vital Signs
  • General survey of the patient
  • Physical examination findings
  • Results from lab or diagnostic studies (think: you observe the results in the MAR)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Expected vs. Unexpected

A

Expected is not always normal (displaced PMI in a big heart) / Unexpected does not always mean abnormal disease (cardiac murmur)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

BMI

A

BMI based on height and weight. In pounds:
[(weight (lb) * 700) / (height inches)] / height inches

In kg: weight (kg) / height^2

Normal: 18.5 - 24.9
Overweight: 25 - 29.9
Obesity: 30.0 - 39.9
Extremely Obese: 40.0+

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Vital Signs (5)

A 
Blood Pressure
Heart rate and rhythm
Respiratory rate and rhythm
Temperature
Pain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Pain

A

5th Vital Sign

Nociceptive or somatic: related to tissue damage

Neuropathic: resulting from direct trauma to the peripheral or central nervous system

Psychogenic: relates to factors that influence the patient’s report of pain (psychiatric conditions, coping style, cultural norms, social support systems)

Idiopathic: no identifiable etiology

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Physical Exam

A

Generally conducted in head-to-toe order, with painful or invasive components done last

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

General Appearance

A
  • Apparent state of health (acute vs. chronic ill)
  • LOC
  • Signs of distress
  • Skin color, obvious lesions
  • Dress, grooming, and personal hygiene
  • Facial expression
  • Odors of body, breath
  • Posture, gait, motor activity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Odors

A

Ketoacidosis –> fruity odor to breath

Liver failure –> ammonia odor to breath

Alcohol –> sweet odor to breath

GI disorders –> fecal odor to breath / old blood

Poor oral hygiene –> bad breath

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Provider Patient Positioning

A

Stand in front, or to the right of the patient, or behind

With GI exam, exam should be on patient’s right side

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Order of Exam Techniques (all except GI)

A

IPPA

INSPECTION
Palpation
Percussion
Auscultation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Order of Exam (Abdomen)

A

IAPP

INSPECTION
Auscultation
Percussion
Palpation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Percussion

A

Listen For: Flatness / Dullness / Resonance / Hyperresonance / Tympany / Loudness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Types of Percussion

A

Direct Percussion - Sinuses

Indirect Percussion - Abdomen

Fist Percussion - CVA tenderness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Percussion Sounds: Flatness

A

Less Less Air, More Tissue // Soft // Muscle (thigh)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Dullness

A

Less Air, More Tissue // Medium // Liver

17
Q

Resonance

A

Air = Tissue // Loud // Lung

18
Q

Hyperresonance

A

Air > Tissue // Very Loud // Hyperinflated Lung (COPD)

19
Q

Tympany

A

Air&raquo_space; Tissue // Loud // Stomach (Gastric Bubble)

20
Q

Ausculation

A

Chest piece secure on SKIN

21
Q

General Survey

A

Documented to help identify a patient and paint a picture of the patient’s overall presentation and status

22
Q

Overall Objective Documentation

A

Should flow logically from the subjective - and should reflect differential diagnoses

23
Q

Objective

A

Physical Exam + lab results, other diagnostic tests

State name of test, then provide values. Avoid things like WNL, or “normal” - allow other readers to make their own interpretation of the values

*If the tests will be ordered, document in P (plan)

24
Q

Pathologic / Pathophyscilogic Process

A

Types

Congenital: born that way?
Inflammatory: knee pain
Infectious
Immunologic
Neoplastic: cancer
Metabolic
Nutritional
Vascular
Traumatic: from an injury?
System failure (cardiac, liver, etc)
Idiopathic: don't know

Start thinking about - where is this coming from?

25
Q

Psychopathologic

A

Mood Disorder
Depression
Headache as an expression of somatization

Are symptoms coming from something else, that isn’t physiologic?

26
Q

Make a hypothesis about the nature of the patient’s problem

A

Then test your hypothesis and establish a working diagnosis

27
Q

Working diagnosis

A

Define problem in terms of structure, process, and cause.

28
Q

Assessment = Impression

A

What you come up with after looking at the patient

Your impression/diagnosis CAN be a symptoms. For instance: back pain, headache

Be careful (ex. hypertension) - it is OK if you don’t know yet just to put the symptom!

29
Q

Differentials

A

List of possible explanations for the symptoms the patient presents with

30
Q

Assessment

A

First thing: chief complaint

Two: also have hypertension (can list out the other things they have) / can put “see past medical history”

31
Q

Examples of Assessment with Differentials

A

Palpitations r/o a-fib, anemia, thyroid disease, anxiety, caffeine, intolerance, ventricular arrhythmias

32
Q

“Worst case scenario”

A

Include worst case… and make sure you have ruled this out based on your findings

6011 Test 1 (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions