Assessment And Clinical Decision Making

Front 1

Four main areas for mental health assessment

Back 1

Appearance

Behaviour

Cognition

Thought processes

Front 2

When assessing radial pulse you should include assessment of which four criteria?

Back 2

Measure radial pulse rate

Evaluate pulse rhythm

Assess amplitude and contour

Palpate arterial elasticity

Front 3

What are you looking for when palpating skin of an adult?

Back 3

Texture, thickness, moisture, temperature, mobility and turgor, oedema

Front 4

Purpose of the health history

Back 4

Lays the groundwork for identifying nursing problems and provides a focus for the physical examination.

Front 5

Areas of questioning during health history of cardiovascular system

Back 5

Chest pain and palpations, difficulties breathing, dizziness, oedema, heart burn, heart defect or murmur, hx of heart surgery/interventions, hypertension or other heart diseases, lifestyle

Front 6

Areas of questioning during health history of both male and female genitalia

Back 6

Urination: difficulties, pain, colour, odour, control, blood.

Sexual dysfunction: performance, libido, performance.

Prior problems, hx of STI, last examination, number of sexual partners, self exams, birth control

Front 7

Areas of questioning during health history of respiratory system

Back 7

Difficulty breathing?

Chest pain?

Coughing? When and how often?

Do you/have you smoked? How much?

Hx of respiratory infections?

Environmental exposures?

Front 8

Areas of questioning during health history of breast assessment

Back 8

Lumps or swelling, redness, warmth, dimpling, change in size or firmness, pain, nipple discharge, hx of breast cancer, hx of breast disease or surgery.

Front 9

Areas of questioning during health history of neurological

Back 9

Numbness or tingling, seizures, headaches, dizziness, changes in senses, difficulty speaking or swallowing, change in muscle control, memory loss, family hx of hypertension, stroke, Alzheimers, ever had a head or spinal cord injury

Front 10

Areas of questioning during health history of auditory system

Back 10

Changes in hearing, ear drainage, pain, dizziness/feeling unbalanced, hx of ear problems, family hx of hearing loss, lifestyle (noise at work)

Front 11

Questions during initial pain assessment

Back 11

Are you experiencing pain now?

Where? Does it radiate or spread?

Other symptoms accompanying pain?

When did it start? What were you doing?

Is it continuous or intermittent?

Describe pain in your own words?

What relieves/increases pain? Any pain therapy?

Front 12

Areas of questioning during health history of eyes

Back 12

Recent vision changes?

Do you see spots or floaters?

Blind spots?

Eye pain or itching?

Excessive watering, eye discharge?

Previous eye problems/surgery/treatments?

Hx of vision loss in family?

Lifestyle? (Exposure to harmful substances etc)

Front 13

Areas of questioning during health history of abdominal system

Back 13

Changes in appetite, dysphagia, food intolerances, abdominal pain, nausea, vomiting, indigestion, constipation, vomiting, changes in bowel habits, past abdo hx, medications, travel

Front 14

Areas of questioning during health history of head and neck

Back 14

Headaches, dizziness/vertigo, neck pain, seizures, surgical hx, swelling, movement limitations, head injury, loss of consciousness, medication

Front 15

Areas of questioning during health history of mouth and throat

Back 15

Sores or lesions, sore throat, bleeding gums, toothache, hoarseness, dysphagia, altered taste, smoking and alcohol consumption, self care behaviours, last dental appt

Front 16

Areas of questioning during health history of nose

Back 16

Discharge, frequent colds, sinus pain, trauma, epistaxis, allergies, altered smell

Front 17

Areas of questioning during health history of musculoskeletal system

Back 17

Recent weight gain, difficulty chewing, joint/muscle/bone pain, past injuries, family hx of arthritis/osteoporosis, exercise pattern, medications, alcohol and smoking, diet, occupation

Front 18

Areas of questioning during health history of peripheral vascular system

Back 18

Changes in skin colour, temperature or texture, pain or cramping in legs, varicose veins, leg ulcers, oedema, swollen glands or lymph nodes, circulation problems, family hx of diabetes, heart disease etc, smoking, exercise

Front 19

Blood pressure

Back 19

Pressure exerted on the walls of the arteries

Front 20

Systolic pressure

Back 20

Pressure of blood in the arteries when ventricles are contracted

Front 21

Diastolic pressure

Back 21

Pressure of blood in the arteries when ventricles are relaxed

Front 22

Order of joint examination

Back 22

Temporomandibular, sternoclavicular, shoulder, elbow, wrist, fingers, thumb, vertebrae, hip, knee, ankle foot

Front 23

Rationale for performing auscultation of the abdomen before palpation or percussion

Back 23

So you do not alter the patients pattern of bowel sounds

Front 24

COLDSPA

Back 24

Character

Onset

Location

Duration

Severity

Pattern

Associated factors

Front 25

Significant information in the four areas of general survery: physical appearance, body structure, mobility and behaviour

Back 25

Physical appearance: skin condition and colour, facial expression, dress and hygiene

Body structure: physical development, build, gender and sexual development

Mobility: posture, gait, body movements and affect

Behaviour:consciousness, speech, apparent age

Front 26

Improper size blood pressure cuff

Back 26

A cuff that is too small may give a false or abnormally high reading

Front 27

What needs to be noted when assessing a skin lesion?

Back 27

Colour, shape, size

Front 28

Neurological objective assessment components

Back 28

Test cranial nerves, inspect muscle groups for size and involuntary movement, test muscle strength and tone, assess balance gait and rapid alternating movements, assess sensory system (spinothalamic and posterior column tracts), assess deep tendon and plantar reflexes

Front 29

3 factors that can cause extraneous noise during ausculatation

Back 29

Rustling of gown, examiner breathing loudly on stethoscope, patients hairy chest

Front 30

Guidelines for distinguishing between S1 from S2

Back 30

S1= Lub S2= Dub S1 starts systole, S2 starts diastole. Space between S1 and S2 is short whereas space between S2 and the start of another S1 is much longer.

Front 31

Explain the statement that normal visual acuity is 6/6 (20/20).

Back 31

This means the patient can distinguish what the person with normal vision can distinguish from 6 metres away.

Front 32

How can you enhance abdominal relaxation?

Back 32

Explain each aspect of the assessment, answer any questions, drape genital areas, warm hands

Front 33

Define and describe the four examination techniques

Back 33

Inspection: using senses to observe/detect normal or abnormal findings

Palpation: using parts of hand to touch and feel for characteristics

Percussion: tapping body parts to produce sound and assess underlying structure

Auscultate: use of stethoscope to listen to heart, lung, bowel sounds

Front 34

Findings that should be noted during abdominal inspection

Back 34

Skin: colour, vascularity, scars, lesions, masses

Umbilicus: colour and location

Abdominal contour, symmetry, pulsations

Front 35

Define bruit and discuss what it indicates

Back 35

An abnormal sound, blowing, swishing or murmuring causes by turbulent flow heard during auscultation.

Front 36

Name and describe the three types of normal breath sounds

Back 36

Bronchial: high pitch, loud, inspiration < expiration, trachea and thorax.

Bronchovesicular: moderate pitch and loudness, inspiration=expiration, over major bronchi.

Vesicular: low pitch, soft, inspiration > expiration, peripheral lung fields

Front 37

Describe the tripod position and when is it utilised?

Back 37

When patient leans forward and uses arms to support weight and lift chest to increase breathing capacity. Often seen in patients with breathing difficulties such as those with COPD.

Front 38

Describe 2 tests which can assess cerebellar function

Back 38

Rhomberg test: stand with arms at side and feet together with eyes closed 20 s. Evaluates balance

Rapid alternating movements: palms up palms down, finger to nose etc, increase speed. Assesses coordination

Front 39

The three areas of assessment on the Glasgow Coma Scale

Back 39

Motor response (6 grades)

Verbal response (5 grades)

Eye opening response (4 grades)

Front 40

Teaching points to include in a testicular self examination

Back 40

Easier after shower/bath

Check both testes one at a time

Use palm of hand to support, roll testis between thumb and fingers to feel for lumps/swelling

Feel along epididymis at the back, soft highly coiled tube, check for swelling

Front 41

How do you assess mood and affect

Back 41

Affect: observation of range and appropriateness of patients emotions

Mood: describe how patient perceives own mood by asking how they are feeling

Front 42

Nosocomial infection

Back 42

Hospital acquired infection, prevented by use of standard precautions

Front 43

Standard Precautions

Back 43

Hand hygiene, personal protective equipment, patient care equipment and instruments, care of environment, patient placement

Front 44

Uses of percussion

Back 44

Eliciting pain, determining location size and shape, determining density, detecting abnormal masses and eliciting reflexes

Front 45

Factors that determine level of blood pressure

Back 45

Cardiac output, blood volume, blood velocity, blood viscosity

Front 46

What is the pupillary light reflex

Back 46

Causes pupils to immediately constrict when exposed to bright light. A direct reflex when exposed to light, indirect when opposite eye constricts when the other is exposed to light

Front 47

What is the Hirschberg test

Back 47

Tests if eyes are in alignment by shining light at eyes and observing where light reflex is located in reference to the pupil