Physical Assessment- Week 1

Flashcards for vocabulary review.

Health Assessment

Use critical thinking to collect, validate, analyze, and synthesize information to make judgments about health status of individuals, families, and communities, forming the foundation for quality nursing care and intervention.

The Nursing Process

1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

7 Facets of Assessments

• Physical Assessment

• Emotional Health

• Social Well Being

• Cultural influence

• Spiritual influences

• Environmental influences

• Development level

Assessing due to a specific patient complaint

Episodic Assessment

Following up with a patient to assess a known or existing problem to monitor the effectiveness of an intervention.

Follow up assessment

Rapid focused assessment conducted when addressing life threatening or unable clinical conditions

Emergency assessment

Critical Thinking

Necessary for excellent clinical judgement. Involves assessing and modifying before acting and thinking outside the box with multidimensional thinking processes.

Full head to toe physical exam

Comprehensive assessment

Comprehensive (Complete) Assessment

Includes a complete health history and full head-to-toe physical exam. Describes the patient's current and past health state and serves as a baseline for future assessments (e.g., annual well visit).

Subjective Data

Symptoms

Objective Data

Signs

(Subjective or objective) Indigestion l

Subjective

(Subjective or objective) Nontender Stomach

Objective

(Subjective or objective) Intermittent cough

Subjective

(Subjective or objective) intact gag reflex

Objective

(Subjective or objective) sore shoulder

Subjective

Social Determinants of Health

The social, economic, and political conditions that influence the health of both individuals and populations.

Implicit Bias

A set of unconscious beliefs or associations that lead to a negative evaluation of a person based on their perceived group identity (e.g., race, gender, LGBTQIA+, age).

Reflect on patterns of emotion and Behavior→ Pause before starting and prepare for potential triggers of bias→ Generate alternative hypothesis for biases anchored in behavior→ Use universal communication and interpersonal skills→ Explore your patients identities→ Explore your patient experience of advice

Continuum of self evaluation

Cultural Humility

"process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners" in effort to address power imbalances and to advocate for others . Includes Self-awareness, Respectful communication and Collaborative partnerships

Trauma-Informed Care

Practices that promote a culture of safety, empowerment, and healing, recognizing the prevalence of trauma and its potential impact on patients.

Therapeutic Communication

Involves listening and understanding the patient's message, facilitating the patient's verbalization and understanding of their feelings, and providing an atmosphere of acceptance and understanding.

Rapport, empathy and boundaries

Foundations of effective Communication

SOLER (Nonverbal communication skills)

Sit squarely/at an angle

Open posture

Lean forward

Eye Contact

Relax

Facilitate, silence, reflection, empathy, clarification/validation

Verbal communication techniques

Confrontation, interpretation, explanation, and summary

Examiner lead verbal communication technique

CC

The primary reason for the patient seeking medical attention, stated in the patient's own words and written in quotation marks.

Chief complaint

HPI

A detailed chronological account of the chief complaint for the ill person, including eight key points of information referred to as an analysis of the symptom.

History of patient illness

PMH

Past medical History

Family Medical History

Includes relationship to the patient, age and health or age and cause of death of each immediate relative, including parents, grandparents, siblings, children, and grandchildren. Includes conditions to ask about: hypertension, CAD, hyperlipidemia, CVA, diabetes, thyroid or renal disease, arthritis, TB, asthma or other lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, as well as symptoms reported by the patient.

Review of Systems (ROS)

All the patient's reported and denied symptoms organized by body system. List reported positives and then denials (negatives).

Inspection, palpitation, percussion, and auscultation

Assessment techniques

Inspection

Visual assessment

Palpation

Using touch to examine the body

Percussion

Tapping to assess underlying structures

Auscultation

Listening with a stethoscope.

When listening with a stethoscope, which side of the stethoscope makes high-pitched sounds used to measure the lung bowel and normal heart sounds and is also firmly placed on the skin

The diaphragm

When using a stethoscope, which side of the stethoscope produces low pitched sounds to measure abnormal heart sounds vascular. Sounds like roots or while taking blood pressure also pressed lightly on the skin.

The bell

Temperature, pulse, respirations, blood pressure, pain, and oxygen saturation

Vital signs

Menstrual cycle, stress, exercise, age, and external temperature

Influences on temperature

Most accurate route of temperature measurement

Temporal artery

What temperature measurement has to be ordered

Rectal

< 96.8 F

Hypothermia

96.8°F to 100.4°F

Normal temperature

98.6°F

Normal oral temperature

99.5°F

Average rectal temperature

97.7°F

Average axillary Temperature

Where is the radial pulse?

Felt on the wrist

100-160 BPM

Normal pulse rate of a newborn

90 to 140 BPM

Average pulse rate of a toddler

70 to 110 BPM

Normal pulse rate of a 4 to 5 year-old

75 to 100 BPM

Normal pulse rate of a 5 to 12-year-old

60 to 100 bpm

Normal pulse rate of an adult

<60 bpm

Bradycardia

>100 bpm

Tachycardia

Where is the coratid pulse?

Neck

Where is the brachial pulse?

Arm

Where is the femoral pulse?

Right on top of your groin

Where is the popliteal pulse?

Behind the knee

Where is the posterior tibial pulse?

Ankle

Where is the dorsalis pedis pulse?

toe

When do you assess respirations?

While the patient is unaware

30 to 60 respirations per min

Newborns

30 to 50 respirations per minute

Infant

20 to 40 respirations per minute

Toddler

15 to 25 respirations per minute

Child

16 to 20 respirations per minute

Adolescent

12 to 20 respirations per minute

Adult

How do you assess respiration

By measuring rhythm, the depth the rate and effort

Sp02

Oxygen saturation

SPO2 of 95 to 100%

Measurement in a healthy person of oxygen saturation

Blood pressure is measured by…

Systolic over diastolic pressure

The difference between systolic blood pressure and diastolic blood pressure equals

MAP, mean arterial pressure

Auscultatory Gap

A period of silence between Systolic Blood Pressure (SBP) and Diastolic Blood Pressure (DBP) which is present in about 5% of people (usually that have hypertension)

65-85/ 45-55 mmHg

Newborn bp

90-99/ 60-65 mmHg

1-4 years old bp

100-110/ 55-60 mmHg

5-12 year old bp

100-120/ 60-75 mmHg

Adolescent bp

<120/<80 mmHg

Adult bp

30-40 mmHg

normal pulse pressure

>100 mmHg

abnormal pulse pressure

120-129/ less then 80 represents what category blood pressure

Elevated

130-139/ 80-89 represents what blood pressure category

High blood pressure (hypertension stage 1)

140 or higher/ 90 and higher represents what blood pressure category

High blood pressure (hypertension stage 2)

Higher than 190/ higher than 120 represents what blood pressure category

Hypertensive crisis (consult your doctor)

Orthostatic vitals

Vitals when standing

When do you take orthostatic vitals

When patient reports fainting

Taking hypertensives

You suspect volume depletion

A drop in systolic blood pressure less than 20 MMHG or a drop in diastolic blood pressure less than 10 MMHG within three minutes of standing up or pulse increase of 20 BMP or more represents what

Orthostatic hypotension

Target Organ Damage

includes damage to the: Heart, Brain, Kidneys, Peripheral Arterial System, and Eyes

Acute Pain

Lasts less than 3-6 months commonly associated with surgery, trauma, and acute illness.

Chronic Pain

Pain NOT associated with cancer or other medical conditions that persists for more than 3-6 months, or Pain lasting more than 1 month beyond the course of an acute illness or injury OR Pain recurring at intervals of months or years

• link to tissue damage to skin muscular skeletal system or viscera, but sensory nervous system system is intact

• Can be acute or chronic

• Usually described as dull, pressing, pulling throbbing, spasmodic or colicky

  example arthritis

Nociceptive (somatic pain)

• Direct consequence of lesion or disease affecting the somatic sensory system

• Might be caused by CNS brain or spinal cord injury from stroke or trauma, PNS disorders, causing pressure on spinal nerves, plexus, or peripheral nerves

• Typically described as electric shock like pins and needles stabbing or burning

Neuropathic pain

We can use the abbreviation OLDCART to assess what

Pain

OLDCART

onset, location, duration character, associated, radiation, and timing

What should you do when these symptoms are present?

• Increase blood pressure and pulse

• Rapid, irregular, respirations

• Pupil dilation

• Increase perspiration

• Increase muscle tension

• Apprehension

• Irritability

• Grimacing

• Guarding

• Verbalization of pain

• Crying infants and children

Pain should be reassessed

BMI is calculated by measuring what

Weight over height

BMI of less than 18.5

Underweight

BMI of 18.5 to 24.9

Normal

BMI of 25 to 29.9

Overweight