Foundational Physical Assessment exam 1

• Therapeutic communication


  A type of professional communication defined as the purposeful, interpersonal, information-transmitting process that leads to client understanding and participation
• Therapeutic communication Example


  • Patient comes in and you are asking questions in a physical assessment about marriage and now the pt is crying. How are you going to assess the patient? You will assess the pt by saying I see that you are upset is there something else you want to discuss
• Normal vital signs in adults

  • Temperature 37° C
  • Blood pressure 120/80
  • Heart rate 60-100 beats per minutes
  • Respiratory Rate 12-18 breath per minutes
  • Blood oxygen 95-100%
• Normal vital signs in Child

  • Temperature 37° C
  • Blood pressure Systolic 86 to 106 and the diastolic from 42 to 63
  • Heart rate 52-156 bpm
  • Respiratory Rate 17 - 25 bpm
  • Blood oxygen 95-100%
• Normal vital signs in Infants

  • Temperature 37° C
  • Blood pressure Systolic 72 to 104 and the diastolic from 37 to 56
  • Heart rate 100-190 bpm
  • Respiratory Rate 30-53
  • Blood oxygen 95-100%
• 85-year-old women with a heart rate of 120 bpm, Respiration rate 25, Blood pressure 140/95. Are these vital signs normal or abnormal?

  This set of vitals would be considered abnormal.
• Levels of consciousness range from normal alertness and attention to many altered states. It starts with confusion and delirium to stupor and coma.
• When completing a physical exam Pt is : alert, awake and oriented. Where would you document this information?

  This information would be documented under level of conciseness.
• Screening assessment


  An activity such as a community fair where they are screening for Blood pressure and cholesterol. It's not a full assessment, it's a screening assessment.
• When screening for nutrition and wanting to understand what the Pt eats it is important to be clear, such as asking what you eat and drink in a typical day to the Pt. It is important to not say what your diet is to the Pt.
• What is the first step to a Physical exam?

  general inspection (observe the Pt and its hygiene)
• Pt come to the ER they had a construction site accident they are bleeding profusely, and he says that they can't feel his legs you noticed that your pt is lethargic and confused what do you need to document in your chart?

  Document exactly what the pt tells you.
• The body temperature is going to be at its lowest in the early morning
• Functional ability


  The actual or potential capacity of an individual to perform the activities and task that can be normally expected.
• Example: Functional ability

  You are getting the history on a pt that is disable and has rheumatoid arthritis what question are you going to ask them to determine their functional ability?

  How does arthritis affect your daily life?
• Pt is now having a bowel movement. They have had diarrhea for 3 days pt is going to become dehydrated. Pt comes to the ER and are talking but they are extremely short of breath, cyanotic with bilateral wheezing and now they can't talk. What type of assessment will you be doing?

  Problem focus
• Anything that has to do with respiration issues will become a problem assessment
• Cyanotic- marked by or causing a bluish or purplish discoloration (as of the skin and mucous membranes) due to deficient oxygenation of the blood (blue)
• Bilateral/symmetric wheezing is caused by: Asthma. The disease is believed to result from the complex interaction of host and environmental factors that increase disease predisposition, with inflammation causing symptoms and structural changes.
• Acute Pain: Pt had surgery and they have pain (won't stay forever its related to some kind of of tissue surgery)
• Choric pain: Cancer
• Objective data - information observed through your senses of hearing, sight, smell, and touch

  while assessing the patient. Examples: Vital signs
• Subjective Data - Information provided by the patient about their health status. Example: Patient reports chest pain when breathing deeply
• When assessing the prostate look for shape, size and mobility.
• What to do when a patient is dizzy after getting out of bed

  1. Assess patient

  2. Have patient sit back in the bed
• Assessing irregular heartbeat

  Take apical pulse for a full minute before doing anything else
• Apical pulse


  Pulse point on the chest at the bottom tip (apex) of the heart
• To obtain patient history when the patient is non-English speaking

  1. Call a translating line

  2. Access hospital interpreter
• Pt is sad and quiet

  Ask pt if they want to talk about it
• Physical abuse example:

  You see your pt and you think that they are a victim of physical abuse, what are you going to tell them?


  I’ve seen many women hurt by their boyfriends or husband does anyone hit you?
• Shift assessment

  When taking over a unit
• Old carts:

  O - on set (when and how the symptoms began)

  L- Location (where is the symptom? Does it range? Or is it localized?

  D- Duration (how long does it last?)

  C- Characteristic (describe the symptom)

  A-Aggravating factors (is it aggravating due to activities?)

  R- Related (any symptoms related?)

  T- Treatment

  S- Severely
• Old carts Example:

  As you interview an 85-year-old pt and she tells you that she has balance problems, and you ask her when do those episodes of imbalance occur? What area of the symptom (old carts) are you pursing?

  It’s aggravating factor
• A Hispanic pt tells an African American nurse "You are African American you can't possibly understand how a person like me feels" what would be the appropriate response by the African American nurse?

  The nurse will encourage the pt to describe what they mean by that.
• Secondary assessment


  Assessment done when the primary patient is unable to communicate, often getting information from a family member or caregiver
• Your pt cannot communicate due to them being in hospice and you are going to get information from the daughter in your assessment. What type of assessment is this?

  Secondary assessment (always document secondary assessment and where you got the source)
• Primary assessment would be when the information is coming from the pt themself.
• Primary prevention exercise- exercising 3x a week
• Pt says that they had influenza imulisation about 15 years ago and his wife says "oh he had a bad reaction" what are you going to ask?

  What kind of reaction? And then say that must've been scary for both of you. This is called therapeutic communication.
• RN interviewing clients about family history


  To determine risk factors