question

Why is assessment of acutely ill patients and their families essential?

answer

information obtained identifies immediate and future needs so a plan of care can be initiated

question

Traditional approaches to Patient Assessment include:

answer

- include a complete evaluation of patient history - comprehensive physical exam of all body systems

question

Progressive care clinicians must balance:

answer

-need to gather data -prioritizing and providing care

question

Collection of assessment data is obtained in:

answer

-phased or staged manner -consistent with pt care priorities

question

What is the crucial element to developing competence in assessing progressive care patients?

answer

-consistent and systematic approach

question

Discuss the importance of a consistent and systematic approach to assessment of progressive care pt and families?

answer

- helps avoid missing subtle signs or details that identify actual or potential problem -indicate a pt's changing status

question

Assessments should first focus on (2):

answer

-patient (focal point of practitioner's attention) -technology (augments info obtained from direct assessment)

question

What are the TWO standard approaches to assessing patients?

answer

-head-to-toe approach -body systems approach

question

Most progressive care nurses use a (2):

answer

-combination systems approach -applied in a top-to-bottom manner

question

Assessment of the progressive care patient begins (2)

answer

-moment nurse aware of pending admission/transfer -continues until transitioning to next phase of care

question

The pre-arrival assessment helps the nurse (3):

answer

-paint an initial picture - to anticipate physiologic and psychological needs -determine appropriate resources needed

question

The information received in the prearrival phase is crucial because (2):

answer

-allows nurse to adequately prepare environment -meet specialized needs of pt/family

question

When should the arrival quick check assessment be obtained?

answer

-immediately upon arrival to the unit

question

What assessment acronym is used in the arrival quick check assessment?

answer

_"ABCDE"

question

Define what the letters in the assessment acronym, "ABCDE" represent.

answer

A = Airway B = Breathing C = Circulation, Cerebral Perfusion and Chief Complaint D = Drugs and Diagnostic tests E = Equipment

question

The FOCUS of the quick check assessment is a quick overview of the:

answer

-adequacy of ventilation and perfusion -to ensure early intervention for life threatening situations -(obtaining a quick overview of the key life-sustaining systems)

question

Why is the arrival quick check is ESSENTIAL because:

answer

-validates that basic cardiac and respiratory function is sufficient

question

When is a comprehensive assessment done?

answer

As soon as possible

question

The timing of the comprehensive assessment is dictated by:

answer

-degree of physiologic stability -emergent treatment needs

question

When the patient is admitted directly to PCU from OUTSIDE the hospital, the comprehensive assessment includes:

answer

-an in depth assessment of PMH and social hx -complete physical exam of each body system

question

If the patient is TRANSFERRED to PCU from another area in the hospital the comprehensive assessment includes:

answer

-review of admission assessment data -comparison to the current assessment

question

The comprehensive assessment is VITAL because:

answer

- it influences successful outcomes -provides invaluable insight into proactive interventions

question

What follows the conclusion of the comprehensive assessment?

answer

- Ongoing assessments begin

question

Define: ongoing assessment

answer

-an abbreviated version of the comprehensive assessment that are more focused and driven by the stability of the pt

question

What do the ongoing assessments determine?

answer

-TRENDS -response to therapy -identify new problems -changes from baseline

question

Name the FOUR types of assessments performed:

answer

-pre-arrival assessment -arrival quick check assessment -comprehensive initial assessment -ongoing assessment

question

Identify the assessment priorities for each of the four types of assessment:

answer

Pre-arrival = prepare environment Quick Check = validates basic cardiac/respiratory function is adequate -Comprehensive = vital to successful outcomes by providing insight into proactive interventions -Ongoing = re-evaluates pt's specific condition, treatments ; response to therapy

question

Admission of an acutely ill pt can be chaotic and staff must be cognizant of:

answer

-accurate assessments ; data gathering to ensure the pt is cared for safely with appropriate interventions.

question

Obtaining inaccurate information on admission can lead to:

answer

-ongoing errors that may not be easily rectified or discovered -lead to poor pt outcomes

question

Obtaining information from an acutely ill pt may be difficult. Name other sources that must be utilized:

answer

-family -electronic health records (EHR) -past medical records -transport records -pt belongings

question

What is of particular importance when a pt is admitted?

answer

-obtaining accurate pt ID -PMH -allergies -current Rx

question

Identifying current meds the pt takes can:

answer

-provide clues to medical condition -contributing facts to the current condition

question

Name THREE types of imperative medical information:

answer

-advance directives -allergies -next of kin

question

What is of particular importance during the assessment?

answer

-risk for pressure ulcers formation -alteration in mental status -falls accurate patient ID

question

Name FOUR things that can contribute to skin breakdown in elderly patients.

answer

-loss of muscle mass -osteoporosis -osteoarthritis -kyphosis

question

Name some safety issues nurses need to be cognizant of as treatment begins.

answer

-accurate programming of pumps infusing high-risk Rx -use all safety equipment available -pre-programmed drug libraries -bar coding technology -ensure safety of invasive procedures

question

Identify the key information that should be included in the pre-arrival report:

answer

-chief complain -diagnosis -reason for admission -pertinent history details -physiologic stability -gender ; age -presence of invasive tubes ; lines -medications being administered -ongoing treatments -pending or completed labs/diagnostic tests -isolation requirements

question

Why is being prepared for isolation needs important?

answer

-prevents potentially serious exposures to patient, room- mates and HC workers

question

What should be VERIFIED prior to the pt's arrival?

answer

-proper functioning of all bedside equipment

question

From the moment the pt arrives in the PCU, what is IMMEDIATELY observed?

answer

- general appearance -assessment of "ABCDE"

question

What type of 'needs' are addressed FIRST?

answer

-Urgent needs

question

Identify actions that take place when pt first arrives in PCU?

answer

-seriousness of problems determined and addressed -connected to monitors & support equip -Rx being admin are verified -essential lab/diagnostic tests ordered

question

List THREE ways the nurse can validate the pt is properly identified:

answer

-hospital wristband -personal ID -family ID

question

When identifying pt allergies, what else must the nurse verify?

answer

-type of reaction that occurs -what, if any, treatment is used to alleviate the allergic response

question

When a pt is transferred to the PCU, who is the LEADER of the receiving team?

answer

-the PCU nurse

question

What are the responsibilities of the PCU nurse?

answer

-assumes responsibility for assessing the "ABCDE's" -directs team in completing delegated tasks

question

Why is having a designated LEADER of the receiving team so critical?

answer

-prevents fragmentation of care -reduces possibility that vital assessment clues overlooked

question

If preliminary assessment deviates from normal then:

answer

-interventions are immediately initiated BEFORE continuing with the arrival quick check assessment

question

How does the nurse verify the patency of the pt airway?

answer

-have pt speak -watching chest rise or fall -both

question

What INITIAL action is initiated if the airway appears compromised?

answer

-verify the head positioned properly to prevent the tongue from occluding the airway

question

What should the upper airway be inspected for before inserting an artificial airway?

answer

-blood -vomitus -foreign objectys

question

What should the nurse ENSURE if a pt has an artificial airway such as a cricothyrotomy or tracheostomy?

answer

-airway is secured properly -note position and size markings

question

Identify THREE characteristics of secretions, that should be assessed when suctioned from the airway?

answer

-amount -color -consistency

question

Identify elements observed when assessing a pt's breathing status?

answer

-rate, depth, pattern -symmetry of breathing -effort -use of accessory muscles

question

When a pt is on mechanical ventilation assess for:

answer

-whether breathing is in synchrony with the ventilator

question

Identify THREE nonverbal signs of respiratory distress>

answer

-restlessness -anxiety -change in mental status

question

Auscultate the chest for:

answer

-presence of bilateral breath sounds -quality of breath sounds -bilateral chest expansion

question

During the arrival quick check assessment, where does auscultation of the chest usually take place?

answer

-anterior chest

question

When chest tubes are present, assess for:

answer

-type (pleural or mediatsinal) -connected to suction (wall or water) -not clamped or kinked -functioning properly (FOCA & DOPE)

question

Define mnemonic: FOCA

answer

-F = Fluid fluctuation with respirations -O = Output -C = Color of drainage (amount and character) -A = Air leak

question

Define mnemonic: DOPE

answer

-D = Dislodgement -O = Obstruction -P = Pneumothorax -E = Equipment functioning properly

question

When assessing circulation:

answer

-palpate a pulse -observe EKG for rate, rhythm and presence of ectopy -BP and Temp

question

When assessing PERIPHERAL perfusion:

answer

-evaluate color, temp, moisture of skin -capillary refill -inspect for active bleeding

question

What is the FOCUS when assessing CEREBRAL perfusion:

answer

-determining the functional integrity of the brain as a whole

question

How do you assess the functional integrity of the brain?

answer

-by rapidly evaluating the gross LOC

question

Define the elements assessed in evaluating the gross LOC.

answer

-Alert -Aware of surroundings -Type of stimulus required to obtain a response ( verbal or painful) -Unresponsive

question

What kinds of things can be assessed during transfer from a stretcher to the PCU bed?

answer

-are the eyes open & watching events -follow simple commands -if unable to speak due to artificial airway, do they nod head appropriately to questions

question

List some reasons why it is NOT advised to use family or friends to translate for a non-English speaking patient.

answer

-protection of pt privacy -not understand appropriate medical terminology -avoid well-intentioned but potential bias

question

In the absence of a history source, practitioners must depend exclusively on what sources of information to identify the potential causes of admission?

answer

-physical findings (presence Rx patches, permanent pacemaker, old surgery scars) -knowledge of pathophysiology -access to prior paper or electronic medical records

question

What does assessment of the chief complaint FOCUS on?

answer

-determining the body systems involved -extent of associated symptoms -time of onset -precipitating factors -severity

question

What additional information is integrated into the priority of the arrival quick check?

answer

-infusing medications -diagnostic tests

question

Identify common DIAGNOSTIC tests obtained during the arrival quick check assessment.

answer

-serum electrolytes -glucose -complete blood count with platelets -coagulation studies -CXR -EKG

question

At what time does the comprehensive assessment begin?

answer

-after completion of the "ABCDE's"

question

If any component of the ABCDE's has not been stabilized ; controlled, what happens next?

answer

-energy is focused FIRST, on resolving the abnormality -THEN, proceeding to the comprehensive admission assessment

question

What are some possible pitfalls that can occur during handoff report?

answer

-safety gaps may occur -omission of pertinent information -miscommunication can result in pt care errors

question

What is an example of a standardized handoff format? What is the advantage of using this format?

answer

-SBAR - it can minimize potential for miscommunication

question

Define mnemonic: SBAR

answer

-S = Situation -B = Background -A = Assessment -R = Recommendations

question

What does the comprehensive assessment determine?

answer

-physiologic and psycho-social baseline -defines pt pre-event health status

question

What does the comprehensive assessment include?

answer

-pt's medical history -brief social history -physical exam each body system

question

Why should additional emphasis be placed on the PMH of patients who are elderly?

answer

-frequently has multiple, co-existing illnesses -taking multiple prescriptive Rx & OTC -

question

What elements of the social history must be addressed in patients who are elderly?

answer

-home environment -support systems -self-care abilities

question

What MUST be taken into consideration when interpreting clinical findings in the elderly patient?

answer

-the coexistence of several disease processes + diminished reserves of body systems results in more RAPID PHYSIOLOGIC DETERIORATION

question

When inquiring about the use and abuse of caffeine, alcohol, tobacco and other substances, questions are aimed at determining what?

answer

-the frequency, amount and duration of use

question

Information revealed during the social history can be verified during the physical assessment by:

answer

-presence of needle track marks -nicotine stains on teeth and fingers -smell ETOH on breath

question

Why should patients be asked about physical and emotional safety in their home environment?

answer

-to uncover potential domestic or elder abuse

question

What are the primary body systems that aging effects?

answer

-Nervous -Cardiovascular/Circulatory -Respiratory -Renal -GI -Endocrine, Hematologic & Immunologic -Skin -Musculoskeletal -Psycho-social

question

Identify specific effects aging has on the NERVOUS system.

answer

-diminished hearing and vision -ST memory loss -altered motor coordination -decreased muscle tone and strength -slower response to verbal and motor stimuli -decreased ability to synthesize new information -increased sensitivity to altered temperature states -increased sensitivity to sedation (confusion/agitation) -decreased alertness states -nerve cells transmit more slowly -increased incidence intracerebral hematomas (due to anticoagulant use)

question

How does nerve cells that transmit more slowly effect the body of an older patient?

answer

-reduces reflexes -reduces sensation -problems with movement & safety -reduced pain perception and control

question

Brain tissue atrophy results in the following:

answer

-stretching parasagittal bridging veins (making them more susceptible to rupture -additional space in cranial vault (that allows bleeding to accumulate before S/Sx of increased ICP present) -higher incidence of chronic subdural hematomas

question

Identify THREE factors that increase bleeding tendancies in older adults:

answer

-anticoagulant therapy (Coumadin, Heparin, Lovenox) -antiplatelet therapy (ASA) -alcohol abuse

question

How does alcohol abuse directly effect bleeding tendancies?

answer

-causes brain atrophy -causes liver damage that precipitates clotting problems

question

Identify age related compromises to the CARDIOVASCULAR system.

answer

-increased effects of atherosclerosis of vessels/heart valves -decreased stroke volume with resulting decreased cardiac output -limited cardiac reserve -decreased myocardial conpliance -increased workload of heart -diminished peripheral pulses -orthostatic hypotension (due to loss of sensitivity of baroreceptors) -left ventricular thickening (decreases filling capacity and delays filling time) -muscle mass reduction (results in decreased contractility) -reduction in total body water (increases risk for dehydration) -anemia

question

Identify THREE reasons why anemia is common in older adults.

answer

-nutritional deficiencies -chronic inflammatory disease -chronic renal disease

question

What may be an indicator of significant physiologic stress?

answer

-heart rate greater than 90 bpm

question

Identify age related compromises to the RESPIRATORY system.

answer

-decreased compliance and elasticity (recoil) -decreased vital capacity -increased residual volume -decreased gag and cough reflexes (increased incidence of aspiration, infection & bronchospasm) -decreased response to hypercapnia -oral/nasal mucosa thinner -atrophy of oral mucosa (lead to poorly fitting dentures) -relaxed musculature of oropharynx (increased incidence of aspiration) -Temporomandibular & C-arthritis (make intubation more difficult) -loss of strength in muscles of respiration & diminshed endurance -rib calcification -respiratory fatigue occurs more easily (resulting in hypoxia)

question

What complications can occur when small airways lose recoil (elasticity) ?

answer

-potential airway collapse -air trapping -uneven distribution of ventilation

question

List THREE factors that reduce arterial oxygen saturation and cardiac output.

answer

-pain -injury -extended supine positioning

question

Identify FOUR effects that rib calcification can have on maintaining adequate ventilation.

answer

-decreases inspiratory/expiratory force -reduces chest expansion -increases RR -reduces tidal volume

question

Following minor thoracic injuries, older patients experience higher complication rates with:

answer

-pulmonary edema -atelectasis -pneumonia

question

When inserting an oral or nasal airway & when suctioning, use caution because:

answer

-mucosa is thinner in older adults -may be on anticoagulant therapy

question

Elderly patients on anticoagulant therapy, requiring insertion of a nasopharyngeal or oropharyngeal airway are at greater risk for what complications?

answer

-swelling -bleeding -hemorrhage

question

Define: hypercapnia

answer

-excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration

question

Identify TWO examples of rheumatic conditions that can make intubating older patients more difficult.

answer

-arthritis -osteoporosis

question

What specific effects can arthritis and osteoporosis have during intubation of older patients?

answer

-limited visualization of vocal chords (due to decreased mobility with the jaw thrust) -increased possibility of C-spine injury during instrumentation

question

Identify age related compromises to the RENAL system.

answer

-decreased glomerular filtration rate -increased risk of fluid and electrolyte imbalances -decreased number of nephrons (limits the ability to concentrate the urine) -diminished sense of thirst (leads to dehydration)

question

Identify age related compromises to the GI system.

answer

-increased presence of dentition problems (dentures) -decreased intestinal mobility -decreased hepatic metabolism -increased risk of altered nutritional states

question

Identify age related compromises to the ENDOCRINE, HEMATOLOGIC & IMMUNOLOGIC system.

answer

-increased incidence of DM; thyroid D/O; anemia; -decreased antibody response & cellular immunity -thyroid function drops (slowing metabolism) -parathyroid levels rise (increasing risk osteoporosis) -increased incidence of metabolic syndrome (Type 2 DM) ( blunting effects of insulin) -aldosterone production drops (predisposing orthostatic hypotension and dehydration)

question

Identify age related compromises to the SKIN.

answer

-decreased skin turgor (due to breakdown of elastin) -increased capillary fragility & bruising -decreased elasticity -decrease thermoregulation -loss of SQ fat = thinning of the skin -decreased ability to sweat

question

Define: thermoregulation

answer

impaired heat conservation, production and dissipation

question

Identify situations that contribute to the risk of compromised thermo-regulation:

answer

-loss of SQ fat & thinning of skin -decreased ability to sweat -neurologic changes -chronic cardiac or thyroid conditions -poor nutrition -psychotropic medications -temperature extremes

question

Identify environmental factors that cause skin to age.

answer

-lifestyle -diet -heredity -sun exposure -smoking -obesity -immobility

question

Identify age related compromises to the MUSCULO-SKELETAL system.

answer

-older adults predisposed to C-injury -osteoporosis -changes in bone density -osteopenia -development of spinal stenosis -increasing rigidity C4-C6 levels -rigidity from neurologic D/O (Parkinson dx) -Kyphosis (limits C-range of motion) -fat and fibrous tissue replaces lean body mass -diminished force of contractile muscle -increased weakness and fatigue -poor exercise tolerance -slower, limited movement -slower & shorter gait, unsteadiness

question

Define: osteoporosis

answer

-reduction in the quantity of bone or atrophy of skeletal tissue

question

Define: osteopenia

answer

-decreased calcification or density of bone; -reduced bone mass

question

Define: kyphosis

answer

-excessive outward curvature of the spine, causing hunching of the back

question

Identify age related compromises to the PSYCHO-SOCIAL system.

answer

-difficulty falling asleep and fragmented sleep patterns -increased incidence of depression & anxiety -cognitive impairment D/O -difficulty with change

question

What THREE techniques are used during the physical assessment of body systems?

answer

-inspection -auscultation -palpation

question

The PAIN assessment includes:

answer

-differentiating acute from chronic pain -related physical symptoms -investigating pt perceptions -emotional reactions to pain -quality and characteristics of pain

question

Identify the TWO divisions of the nervous system.

answer

-central -peripheral

question

The CRANIAL NERVES are in which division of the nervous system?

answer

-peripheral

question

In the acutely ill patient, the majority FOCUS of evaluating the nervous system is on which division?

answer

-central nervous system

question

Name THREE factors that can alter CNS functioning.

answer

-physiologic status -psychological impact of acute illness -pharmacologic interventions

question

What is the single most important indicator of cerebral functioning?

answer

-LOC

question

INSPECT the pupils for:

answer

-size, shape, symmetry -reactivity to direct light

question

When interpreting the implication of ALTERED pupil size, remember:

answer

-medications may affect pupil size (atropine, MS, illicit Rx) -some people have unequal/unreactive pupils normally

question

When assessing motor function of extremities, observe:

answer

-symmetry -quality & strength

question

Name TWO examples of common motor strength exercises.

answer

-squeeze hands -plantar flexing/dorsiflexing

question

Name TWO ways the nurse can 'estimate' strength and quality of movements?

answer

-observing activities such as pulling against restraints -thrashing

question

What should the nurse check if the patient has no voluntary movement or is unresponsive?

answer

-the gag reflex

question

If a head trauma is involved or suspected, check for:

answer

-signs of fluid leakage around nose or ears

question

Why are cranial nerves III, IV and VI routinely assessed in facial trauma?

answer

-they evaluate Extra-occular movements (EOM) of the eyes

question

What assessment is the baseline standard for SCI, extremity trauma and epidural analgesia?

answer

-sensory testing

question

When evaluating mental status, observe:

answer

-orientation to person, place and time -state understanding of what is happening - eye contact - pressured/muted speech -rate of speech

question

What is a patient's rate of speech consistent with?

answer

-psychomotor status

question

Cognitive impairments are exacerbated during an acute illness due to:

answer

-physiologic changes -Rx -environmental changes

question

Identify common DIAGNOSTIC tests pertinent to the nervous system include:

answer

-serum electrolytes -urine electrolytes -urine osmolarity -urinary specific gravity -drug toxicology -ETOH level

question

Identify the FOCUS of assessments of these body systems:

answer

-Nervous = evaluating the CNS -CV = evaluating central/peripheral perfusion -Resp = oxygenation ; ventilation -Renal = function of kidneys ; impact on fluid volume -GI = nutritional ; fluid status -Endocrine = hormonal regulation -Hematologic = oxygen-carrying capacity of blood and clotting mechanisms -Immunologic = fighting infection -Integumentary = intactness of the skin

question

If a patient is on telemetry monitoring, assess the ECG for:

answer

-T-wave abnormalities -ST segment changes -determine the PR, QRS, and QT intervals -abnormalities/indications of myocardial damage -electrical conduction problems -electrolyte imbalances

question

If treatment decisions will be based on the cuff pressure, which are is used?

answer

-the pressure is taken in BOTH arms

question

A difference of how many mmHg between a cuff BP and an arterial line pressure, require a decision to be made as to which pressure is the most accurate and will be followed for future treatment decisions?

answer

-10 - 15 mmHg

question

When assessing the skin, INSPECT:

answer

-color -temperature -nail color -capillary refill -edema

question

When evaluating the color and temperature of the skin, emphasis is placed on observing the:

answer

-lips -mucous membranes -distal extremities

question

Name THREE areas where dependent edema frequently occurs:

answer

-feet -ankles -sacrum

question

AUSCULTATE heart sounds for:

answer

-S1 and S2 -quality, intensity and pitch -presence of extra heart sounds (murmers, clicks, rubs) -any changes with RR or pt position

question

PALPATE the peripheral pulses for:

answer

-amplitute -quality

question

Identify common DIAGNOSTIC tests pertinent to the cardiovascular system include:

answer

-electrolyte levels -CBC -coagulation studies -lipid profiles -drug levels of commonly used CV medications

question

What are the THREE most common cardiac enzyme levels drawn for complaints of chest pain or suspected chest trauma?

answer

-troponin -creatine kinase MB -B-natruretic peptide

question

Identify FOUR reasons why a 12 lead ECG might be ordered?

answer

-complaints of chest pain -irregular rhythms -suspected myocardial bruising -baseline

question

What TWO questions should a nurse ask if continuous infusions of medications, such as antiarrhythmics, are being administered?

answer

-ensure infused through appropriately sized vessel -compatible with any piggybacked IV solutions

question

INSPECTION of the respiratory system assessment includes:

answer

-rate, rhythm -symmetry chest wall movement -productive cough/secretions suctioned ; color, amount and consistency -trachea midline or shifted -thoracic cavity shape -AP diameter -structural deformities (kyphosis or scoliosis)

question

PALPATION of the respiratory system assessment, includes:

answer

-equal chest excursion -presence of crepitus -areas of tenderness or fractures

question

During AUSCULTATION of the anterior/posterior chest, listen for:

answer

-bilateral breath sounds -presence of air movement -adventitious sounds (crackles, wheezes) -quality ; depth -length ; pitch of inspiratory/expiratory phases

question

Arterial Blood Gases (ABG's) are used to assess:

answer

-oxygenation -ventilatory status -acid-base balance

question

Hemoglobin and Hematocrit values are used to assess:

answer

-impact on oxygenation -fluid balance

question

In the patient on a mechanical ventilator, VERIFY:

answer

-ventilatory mode -tidal volume -RR -positive end expiratory pressure (PEEP) -% of oxygen against prescribed settings

question

In the patient on a mechanical ventilator, OBSERVE:

answer

-presence/absence spontaneous breaths -rate and average tidal volume of each breath, if present -amount of pressure required to ventilate pt

question

In the patient with a tracheostomy, OBSERVE:

answer

-size and type -location

question

In the patient receiving BiPAP, OBSERVE:

answer

-pressure settings against ordered parameters -tolerance to full face mask/nasal mask

question

In the patient with chest tubes, OBSERVE:

answer

-area around insertion site for crepitus -amount and color of drainage -air leak present -type of drainage system (underwater seal or suction)

question

What TWO parameters are used to assess the function of the RENAL system?

answer

-urinary characteristics -electrolyte status

question

In the patient with a FOLEY catheter, observe:

answer

-amount and color of urine -abnormal presence of glucose, protein, blood

question

INSPECT the external genitalia for:

answer

-inflammation -swelling -ulcers -drainage

question

In the patient with a suprapubic catheter or a ureterostomy, INSPECT:

answer

-position of drainage tube -amount and characteristics of drainage -any leakage around drainage tube

question

Identify common DIAGNOSTIC tests pertinent to the renal system:

answer

-urinalysis -serum electrolyte levels -blood urea nitrogen (BUN) -creatinine -urinary and serum osmolarity

question

INSPECTION of the abdomen includes:

answer

-overall symmetry -contour (flat, round, protuberant, distended) -discoloration or straie

question

What FOUR factors are used to evaluate the nutritional status of a patient?

answer

-weight -muscle tone -condition of oral mucosa -lab values (serum albumin; transferrin)

question

AUSCULTATION of the abdomen includes:

answer

-bowel sounds in all four quadrants -characteristics and frequency -adventitious sounds (friction rubs, bruits, hums)

question

How are BOWEL SOUNDS auscultated?

answer

-clockwise fashion in all four quadrants -note frequency -presence/absence of sounds

question

What are the FOUR ratings for bowel sounds?

answer

-absent -hypoactive -normal -hyperactive

question

Before noting ABSENT bowel sounds, a quadrant should be auscultated for how long?

answer

-60 - 90 seconds

question

PALPATION of the abdomen helps determine:

answer

-areas of fluid -rigidity -tenderness -pain -guarding (rebound tenderness)

question

Why do you auscultate BEFORE palpation?

answer

-palpation may change frequency and character of the peristaltic sounds

question

In a patient with GI drainage tubes, OBSERVE:

answer

-location -function -characteristics of drainage -validate proper placement -ensure patency -drainage/leakage around tubes

question

INSPECT emesis and stool for:

answer

-occult blood

question

INSPECT ostomies for:

answer

-location -color of stoma -peristomal skin condition -type of drainage

question

Identify common DIAGNOSTIC tests pertinent to the hematologic system:

answer

-evaluation of RBC's -coagulation studies

question

Diminished RBC's may affect:

answer

-oxygen-carrying capacity of the blood

question

Identify common S/Sx of anemia (diminished RBC's):

answer

-pallor -cyanosis -light-headedness -tachypnea -tachycardia

question

Insufficient clotting factors are evidenced by:

answer

-bruising -oozing from puncture sites/mucous membranes -overt bleeding

question

Identify common DIAGNOSTIC tests pertinent to the immunologic system:

answer

-white blood cells (WBC's) -differential counts

question

List additional things that can be indicative of underlying infection?

answer

-puncture sites/mucous membranes for oozing drainage -inflamed/reddened areas -spiking or persistent low grade temp

question

INSPECTING the skin involves:

answer

-head-to-toe, A - P, & between skin folds skin integrity -color, temp, turgor -rashes, striae, discoloration, scars, lesions -abrasions, pressure ulcers, wounds -note size, depth, presence/absence of drainage

question

Name factors that can affect communication:

answer

-culture -developmental stage -physical condition -stress -perception -neurocognitive deficits -emotional state -language skills

question

What non-verbal clues can provide important information about the patient?

answer

-body gestures -facial expressions -eye movements -involuntary movements -changes in HR,BP and RR

question

Name the TWO ways anxiety is exhausting.

answer

-physhologically -physiologically

question

How does being in a prolonged state or arousal (anxious) negativelly affect a pt's recovery?

answer

-uses up the adaptive reserves needed for recovery

question

List some of the environmental stressors in the PCU that can contribute to increased anxiety in patients.

answer

-constant auditory/tactile stimuli -forced isolation from social supports -dependency -loss of control -trust in unknown care providers -helplessness -inability to solve problems

question

List the S/Sx that are warning signs of escalating anxiety.

answer

-restlessness -distractibility -hyperventilation -unrealistic demands for attention

question

List some of the medications that can induce anxiety?

answer

-interferon -corticosteroids -ACE inhibitors -vasopressors -abrupt withdrawal from benzodiazepines, caffeine, nicotine and narcotics

question

List additional etiologic variables associated with anxiety.

answer

-pain -sleep loss -delirium -hypoxia -ventilator synchchronization/weaning -fear of death -loss of control -high tech equipment -dehumanizing setting -admission to PCU

question

Identify manipulative behaviors patients use to cope and feel safe when their anxiety and stress escalates.

answer

-impuslsivity -deception -low tolerance for frustration -unreliability -superficial charm -splitting among the provider team -avoidance of rules or limits

question

What behavior is commonly used by patients to blunt the stimuli and stress of their environment?

answer

-withdrawal -request sedatives, sleeping medications -frequent requests for pain Rx

question

Name some common objects of fear that influence a patient's ability to cope.

answer

-treatments -procedures -pain -separation

question

List some of the specific fears associated with the dying process.

answer

-unknown -loneliness -loss of body -loss of self-control -suffering -pain -loss of identity -loss of everyone loved by patient

question

Name the phases of the grieving process.

answer

-denial -shock -anger -bargaining -depression -acceptance

question

Define: advance directive

answer

-a physician order for life sustaining treatment (POLST)

question

When does transition or discharge planning start?

answer

-arrival of the patient to PCU

question

Identify FIVE situations in which an ongoing assessment should occur:

answer

-caregivers change -before/after major procedure -before/after transport off the floor -deterioration in physiologic or mental status initiation of any new therapy

PCCN: Chapter 1 – Assessment of Progressive Care Patients and Their Families – Flashcards

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