Bedside Assessment Flashcards

Three primary components of patient assessment

Medical record review, patient interview, and physical examination.

Is the medical record considered infallible?

No.

Warning about medical records

They may contain errors.

Medical hierarchy

MD/DO → NP/PA → RN/RT.

Who is highest in the medical hierarchy?

MD/DO.

Who follows MD/DO in the hierarchy?

NP/PA.

Who follows NP/PA in the hierarchy?

RN/RT.

What does SOAP stand for?

Subjective, Objective, Assessment, Plan.

What does the 'S' in SOAP represent?

Subjective.

What does the 'O' in SOAP represent?

Objective.

What does the 'A' in SOAP represent?

Assessment.

What does the 'P' in SOAP represent?

Plan.

Four actions associated with assessment

Appreciate, confirm, further evaluate, and decide.

Description of subjective information

Perceived/observed.

Description of objective information

Proven and measurable.

Major difference between subjective and objective information

Objective information is measurable; subjective information is perceived.

When should the chart review be performed?

Before entering the patient's room.

What should you know before entering the patient's room?

The patient's chief complaint.

What does CC stand for?

Chief complaint.

What does the chief complaint identify?

The patient's present illness/problem that brought them to care.

Types of history to review in chart

General/medical, social, occupational, and environmental history.

Social history involves

Voluntary intake or behaviors such as smoking and drinking.

What category does smoking history belong to?

Social history.

What category does drinking/alcohol use belong to?

Social history.

What does occupational history describe?

What the patient does to get paid.

A patient's job belongs to what portion of the history?

Occupational history.

What does environmental history assess?

Things or exposures the patient has been around.

What should the RT look for when assessing occupational and environmental exposures?

Exposure to inhaled particulates and irritants.

Importance of occupational/environmental exposures in respiratory assessment

They may expose the patient to particulates and irritants that are breathed into the respiratory system.

Additional history categories on PowerPoint

Geographic history, past medical history, and family history.

Three purposes of the patient interview

Establish rapport, gather information, and monitor changes in the patient's condition.

Type of questions to use during patient interview

Open-ended questions.

One simple way to establish rapport with a patient

Share your name.

Another simple way to establish rapport

Show the patient that you care.

Why is rapport important during the patient interview?

It helps establish an effective patient-caregiver interaction while gathering information.

What can the interview help the RT monitor besides gathering information?

Changes in the patient's condition.

Characteristics to assess in patient's general appearance

Facial expression, level of distress, positioning, and hygiene.

What should the RT observe about the patient's face?

Facial expression.

Severity aspect to evaluate during general appearance

Level of distress.

Physical arrangement to evaluate during general appearance

Positioning.

Personal-care characteristic to assess during general appearance

Hygiene.

Additional characteristics mentioned in observation speaker notes

Alertness, mood, general character, and mental capacity.

What to observe regarding patient's consciousness during general observation?

Alertness.

Emotional characteristic to observe

Mood.

Cognitive characteristic included in general observation

Mental capacity.

What must RT do when documenting a patient's level of distress?

Justify it with observable findings.

Observable finding that can justify documentation of respiratory distress

Nasal flaring.

Another observable finding that can justify documentation of respiratory distress

Accessory muscle use.

Why shouldn't RT write 'patient in respiratory distress' without additional findings?

The level of distress should be supported by objective observations.

Approximate range of personal space

2–4 feet.

Approximate range of social space

4–12 feet.

Which is closer to the patient: personal or social space?

Personal space.

RT standing approximately 3 feet from a patient is in what space?

Personal space.

RT standing approximately 8 feet from a patient is in what space?

Social space.

Distance separating personal space from social space in lecture material

Personal space is approximately 2–4 feet; social space is approximately 4–12 feet.

What is the supine position?

Lying on the back facing upward.

A patient lying flat on their back is in what position?

Supine.

What is the prone position?

Lying flat on the stomach.

A patient lying with the anterior surface of the body downward is in what position?

Prone.

How does the study guide describe Semi-Fowler position?

The patient is lying at an angle, such as in a hospital bed.

What is Trendelenburg position?

The patient lies on the back with the feet elevated higher than the head.

In Trendelenburg, which is higher: the feet or head?

Feet.

What is reverse Trendelenburg position?

The patient lies on the back with the head higher than the feet.

In reverse Trendelenburg, which is higher: the head or feet?

Head.

What is left lateral decubitus?

The patient is lying with the left side down.

What is right lateral decubitus?

The patient is lying with the right side down.

If the patient's left side is dependent against the bed, what position is the patient in?

Left lateral decubitus.

If the patient's right side is dependent against the bed, what position is the patient in?

Right lateral decubitus.

Major positional difference between Trendelenburg and reverse Trendelenburg

Trendelenburg has the feet higher than the head; reverse Trendelenburg has the head higher than the feet.

Mnemonic used during patient interview to investigate the patient's problem

OLDCART.

What does OLDCART stand for?

Onset, Location, Duration, Character, Associated manifestations, Relieving factors, Treatment.

What does the 'O' in OLDCART stand for?

Onset.

What does onset determine?

When the problem happens/began.

What does the 'L' in OLDCART stand for?

Location.

What does location determine?

Where on the body the problem occurs.

What does the 'D' in OLDCART stand for?

Duration.

What does duration determine?

How long the problem has been going on.

What does the 'C' in OLDCART stand for?

Character.

What does character ask the patient to do?

Describe the problem or sensation.

What does the 'A' in OLDCART stand for?

Associated manifestations.

What are associated manifestations?

Symptoms occurring along with the main problem.

What does the 'R' in OLDCART stand for?

Relieving factors.

What do relieving factors identify?

What makes the problem better.

What does the 'T' in OLDCART stand for?

Treatment.

What does the treatment portion of OLDCART evaluate?

Measures/interventions used to help the patient's problem.

When did your chest pain start? evaluates which OLDCART component?

Onset.

Where do you feel the pain? evaluates which OLDCART component?

Location.

How long has this been happening? evaluates which OLDCART component?

Duration.

Describe what the pain feels like evaluates which OLDCART component?

Character.

What other symptoms happen with your shortness of breath? evaluates which OLDCART component?

Associated manifestations.

What makes your breathing better? evaluates which OLDCART component?

Relieving factors.

What has been done to treat the problem? evaluates which OLDCART component?

Treatment.

Measurement used to quantify a patient's cigarette-smoking history

Pack-years.

Formula for pack-years

(Cigarettes per day ÷ 20) × years smoked.

How many cigarettes are treated as one pack in the pack-year formula?

20 cigarettes.

What does smoking 20 cigarettes per day equal in packs per day?

1 pack/day.

What does smoking 10 cigarettes per day equal in packs per day?

0.5 pack/day.

A patient smoked 1 pack/day for 20 years. What is the smoking history?

20 pack-years.

A patient smoked 2 packs/day for 10 years. What is the smoking history?

20 pack-years.

A patient smoked 10 cigarettes/day for 30 years. What is the smoking history?

15 pack-years.