Health Assessment/SBAR - REVISED Flashcards
(81 cards)
A nurse tells you a pt is stuporious. What does stuporious mean?
Pt is extremly unresponsive; must be shaken to be aroused
What are adventitous breath sounds?
abnormal sounds
IN ORDER, name the 4 techniques to used during physical assessment (not for abdominal assessment)
- Inspection
- Palpation
- Percussion
- Ascultation
IN ORDER, name the 4 techniques to used during an ABDOMINAL assessment
- Inspection
- Auscultation
- Percussion
- Palpation
^BASED ON BOOK (nLM); eapen said: inspection, asculation, palp, percuss
Which physical assessment technique would you use to assess the density of tissue?
A) Inspection
B) Palpation
C) Percussion
D) Asculation
C) Percussion, helps to assess the density of tissues because the act of tapping the body with the fingertips produces vibrations and sound waves. The characteristics of the sounds that are produced indicate the density of the underlying tissue
What assessment technique is used to sense vibrations and underlying structures?
A) Inspection
B) Palpation
C) Percussion
D) Asculation
B) Palpation, uses the sense of touch to assess various characteristics, including vibrations within the body and the shape of underlying structures.
What part of the hand is used to assess surface temperature?
Back of hand
Different parts of the hands are better at assessing certain characteristics of the body. Organize the characteristics into a category (Hint: Which part of the hand is used to assess certain characteristics?). ANSWERS CAN BE USED MORE THAN ONCE
Category:
- Palmar Surface
- Fingers/Fingerpads
Characteristics:
- Firmness
- Tenderness
- Consistency
- Shape
- Contour
Palmar Surface
- Firmness
- Tenderness
- Shape
Fingers/Fingerpads
- Firness
- Tenderness
- Shape
- Contour
- Consistency
Define this type of health assessment: Comprehensive Assessment
(Define it/When do you perform this assessment? What does it provide?)
- Conducted upon admission to a healthcare facility
- Provides baseline
A ___________ assessment includes a full health history and physical assessment
Comprehensive Assessment (Admission)
Compare a Health History from a Physical Assessment based on the type of data it collects
- Health history: collection of subjective data
- Physical assessment: collection of objective data
Define this type of health assessment: Ongoing/Partial/Follow Up Assessment
(Define it/When do you perform this assessment? What does it provide?)
- Conducted at regular intervals during your shift
- Concetrates on identified health problems to monitor for positive or negative changes and evaluate effectiveness of interventions
Define this type of health assessment: Focused Assessment
(Define it/Why its conducted; Provide an example)
- Conducted to assess a specific problem (usually involves focus on 1-2 body systems)
- Ex: Chest pain -» do EKG
Define this type of health assessment: Emergency (Triage) Assessment
(Define it/Why is it conducted)
- conducted in life-threatening or unstable situations
Which equipment used during physical examination visualizes interior eye structures?
Ophthalmoscope
Which equipment used during physical examination examines external ear canal and tympanic membrane?
Otoscope
Which equipment used during physical examination screens for distant vision?
Snellen Chart
Which equipment used during physical examination visualizes lower and middle turbinates of the nose?
Nasal Speculum
Which equipment used during physical examination examines vaginal canal and cervix?
Vaginal Speculum
Which equipment used during physical examination tests auditory function and vibratory perception?
Tuning Fork
Which equipment used during physical examination tests deep tendon reflexes and determines tissue density?
Percussion Hammer
Compare subjective vs objective data
Subjective data: What the pt says/feels
Objective data: Measurable/observable
For each statement below, determine whether the data presented is subjective or objective:
- The nurse observes that the patient is shivering and has goosebumps.
- “I have a headache that won’t go away.”
- The nurse measures the patient’s blood pressure as 130/85 mmHg.
- The patient’s temperature is 100.4°F (38°C).
- The nurse documents that the patient’s respiratory rate is 24 breaths per minute.
- Pt reports pain 8/10 on left leg.
- “I feel nauseous and lightheaded.”
- The nurse notes that the patient’s skin is pale and cool to the touch.
- Female, age 22, smoker for 5+ years.
- Pt family states, “She hasn’t had an appetite all day.”
Subjective Data
- “I feel nauseous and lightheaded.”
- Female, age 22, smoker for 5+ years
- Pt reports pain 8/10 on left leg
- Pt family states “ She hasn’t had an appetite all day.”
- “I have a headache that won’t go away.”
Objective Data
- The patient’s temperature is 100.4°F (38°C).
- The nurse observes that the patient is shivering and has goosebumps
- The nurse measures the patient’s blood pressure as 130/85 mmHg
- The nurse notes that the patient’s skin is pale and cool to the touch
- The nurse documents that the patient’s respiratory rate is 24 breaths per minute.
A nurse is conducting a comprehensive patient assessment. Which of the following are key purposes for perforing a health assessment? (Select all that apply)
A. Identify actual and potential health problems
B. Establish a baseline
C. Identify changes in status
D. Collect, validate, and analyze subjective and objective data to determine the patient’s health status
E. Ignore minor patient complaints
F Identify patient strengths
G: Only documenting the patient’s current complaints
A. Identify actual and potential health problems
B. Establish a baseline
C. Identify changes in status
D. Collect, validate, and analyze subjective and objective data to determine the patient’s health status
F Identify patient strengths
