Podcast
Questions and Answers
What does the 'S' in the OPQRST pain assessment stand for?
What does the 'S' in the OPQRST pain assessment stand for?
What is the correct order of assessment techniques for the abdomen to avoid altering bowel sounds?
What is the correct order of assessment techniques for the abdomen to avoid altering bowel sounds?
Which assessment technique involves listening to the heart, lung, and bowel sounds?
Which assessment technique involves listening to the heart, lung, and bowel sounds?
What are the 6 Ps of Compartment Syndrome?
What are the 6 Ps of Compartment Syndrome?
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Which of the following is NOT a purpose of physical assessment?
Which of the following is NOT a purpose of physical assessment?
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When assessing the skin, which condition indicates jaundice?
When assessing the skin, which condition indicates jaundice?
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Which of these signs indicates chronic venous insufficiency?
Which of these signs indicates chronic venous insufficiency?
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What does PEARRLA stand for in cranial nerve assessment?
What does PEARRLA stand for in cranial nerve assessment?
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What is the primary purpose of obtaining a patient's health history?
What is the primary purpose of obtaining a patient's health history?
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Which method is considered the most accurate for measuring core temperature?
Which method is considered the most accurate for measuring core temperature?
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What would likely cause an increased pulse rate in a patient?
What would likely cause an increased pulse rate in a patient?
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In order to effectively evaluate a patient's functional capacity, which component should be assessed?
In order to effectively evaluate a patient's functional capacity, which component should be assessed?
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Which of the following is a common cause of decreased respiratory rate?
Which of the following is a common cause of decreased respiratory rate?
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What is the first step in establishing therapeutic communication with a patient?
What is the first step in establishing therapeutic communication with a patient?
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What should be monitored to evaluate a patient's oxygen saturation level?
What should be monitored to evaluate a patient's oxygen saturation level?
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Which symptom would indicate an abnormal change in patient condition during assessment?
Which symptom would indicate an abnormal change in patient condition during assessment?
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Which sign is NOT associated with shock?
Which sign is NOT associated with shock?
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Which of the following signs indicates fluid volume overload?
Which of the following signs indicates fluid volume overload?
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In Cushing's Triad, which symptom is NOT present?
In Cushing's Triad, which symptom is NOT present?
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Which therapeutic communication technique involves maintaining eye contact?
Which therapeutic communication technique involves maintaining eye contact?
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What is a priority when managing a patient in mania due to bipolar disorder?
What is a priority when managing a patient in mania due to bipolar disorder?
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Which ego defense mechanism is characterized by refusing to accept reality?
Which ego defense mechanism is characterized by refusing to accept reality?
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What is a common sign of substance withdrawal?
What is a common sign of substance withdrawal?
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Which of the following is NOT a type of personality disorder?
Which of the following is NOT a type of personality disorder?
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Study Notes
History Taking and Physical Examination
- Recognize cues to determine if patient condition is normal or abnormal for the patient
- Identify warning signs and changes in patient condition
- Subjective Data: Symptoms reported by the patient
- Objective Data: Signs observed or measured, including assessment findings and medical records
- Health History: Includes current medical condition, family history, lifestyle factors, and medications
- Purpose of health history: To understand baseline health, risk factors, and medical history
- Functional Assessment: Evaluates patient's daily activities and ability to live independently assessing physical, emotional, and social functioning
- Cultural Assessment: Understands cultural beliefs, practices, and SDOH (social determinants of health), including financial, language, transportation barriers, and important cultural practices, e.g., dietary restrictions, preferences that influence health and care
- Therapeutic Communication: Establishes trust, rapport, and empathy using active listening and open-ended questions
- Avoid nontherapeutic communication techniques (e.g., giving advice, judgmental comments)
Vital Signs
- Temperature: Axillary (preferred for babies), temporal or tympanic (common for children and adults), rectal(for core temp measurement)
- Pulse: Newborn (110-160 bpm), Adult (60-100 bpm)
- Respiratory Rate: Count for 1 full minute. Observe rate, depth, patterns, and effort
- Increased Pulse/Respiration: Fever, pain, anxiety, activity, stimulants
- Decreased Pulse/Respiration: Sleep, medication, certain conditions (e.g., heart block)
- Blood Pressure: Increased: Pain, stimulant use, fluid overload; Decreased: Fluid volume deficit, dehydration, shock
- O2 Saturation: Measure for oxygen sufficiency
- Pain (6th Vital Sign): Use OPQRST Assessment, where O=onset, P=provocation/palliation, Q=quality, R=radiation, S=severity, and T=timing
Physical Assessment
- Purpose: To gather data on the patient's health status, identify abnormalities, and guide care planning
-
Techniques:
- Inspection: Observe the patient for visible signs
- Palpation: Feel for abnormal masses, tenderness, or changes in temperature
- Percussion: Tap areas to assess underlying structures (e.g., dullness, tympany)
- Auscultation: Listen to heart, lung, and bowel sounds
- Abdomen: Inspect, auscultate, percuss, palpate (important order to avoid altering bowel sounds)
- General Impression: Appearance, posture, facial expression, hygiene, tone, position, distress level, mental status
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HEENOT (Head, Eyes, Ears, Nose, Throat):
- PEARRLA: Pupils Equal and Reactive to Light and Accommodation.
- EOMI: Extraocular Movements Intact.
- Tongue and mucosa: Indicators of hydration
- Palate: Check for pallor (anemia), jaundice
- Chest/Thorax: Cardiac (S1, S2, S3, S4, murmurs, PMI), chest wall (crepitus, tactile fremitus, chest expansion)
- Lungs: Auscultate for abnormal sounds (rhonchi, wheezes, crackles, pleural friction rub)
- Abdomen: Inspect and palpate for abnormalities in 4 quadrants
- Percussion Sounds: Flat (bone), dull (solid organ), tympany (hollow organ).
Focused Assessments
- Purpose: Focus on specific complaints, injuries, or problems. Prioritize care based on urgency
- Common Assessments: Check pulses and perfusion, assess pain, inspect injuries before palpation to avoid worsening damage
Shock vs. Increased ICP
- Shock: Tachycardia, tachypnea, hypotension, restlessness, anxiety, pale, cool, clammy skin, decreased urine output
- Increased ICP: Bradycardia, bradypnea, hypertension with widening pulse pressure, unequal or dilated pupils, anxiety, restlessness, headache (Cushing's Triad: Hypertension, bradycardia, irregular respirations)
Fluid Volume Balance
- Fluid Volume Deficit (FVD): Tenting/poor turgor, dry cracked tongue, tachycardia, tachypnea, hypotension, sunken fontanelles, sunken orbits in pediatric cases
- Fluid Volume Overload (FVO): Edema, crackles, JVD, weight gain, tachycardia, tachypnea, hypertension
Other Topics
- Psychiatric Mental Health Nursing: Mental illness occurs when a person cannot adapt to stress, causing functional impairment; includes ego defense mechanisms: Denial, displacement, rationalization, repression; therapeutic communication - SOLER Technique (sit, open posture, lean forward, eye contact, relax); Suicide Risk assessment (asking about thoughts, intentions, plans, and means); bipolar disorder (Lithium management, safety, monitoring for hyperactivity and poor judgment); schizophrenia (major disturbances in thought, hallucinations); Anxiety and phobias; substance use; personality disorders (Cluster A, B, and C)
- Maternal Newborn Nursing: Antepartal care (inquire about safety, habits, drug use, immunizations, offer genetic testing, TORCH infections, and teratogens), monitor fetal growth). Intrapartal Care (Labor stages: 1st stage; Cervix effaces and dilates; 2nd stage; Pushing and delivery; 3rd stage; Placenta delivery); preterm labor(steroids, antibiotics); postpartum care(Hemorrhage risk, infection); newborn care(APGAR scores, preterm baby concerns; NAS babies, withdrawal symptoms monitoring).
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Description
This quiz focuses on the essential skills of history taking and physical examination in a healthcare setting. It covers recognizing normal vs. abnormal patient conditions, understanding subjective and objective data, and the importance of health and cultural assessments. Test your knowledge on effective communication and patient evaluation techniques.
