Head-to-toe and Health History Data Collection
What systems are included in a head-to-toe data collection?
What are neuro, cardiovascular, respiratory, and gastrointestinal
Position a patient should be in when receiving trach care and suctioning.
What is fowler's or semi-fowler's?
Normal Adult RR and HR.
What is stridor, rhonci, wheezes, rales/crackles, and pleural rub.
Name three causes of hyperactive bowel sounds
What is diarrhea, UC, Chron's, C-diff, IBS?
How many cranial nerves are there that are tested in a full neuro exam?
What is 12?
(Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Acoustic, Glossopharyngeal, Vagus, Accessory, Hypoglossal) Nerves.
At what point in the process do you change the trach ties?
What is end of the procedure/last step?
List three abnormal findings when auscultating heart sounds
What are tachycardia, bradycardia, murmur, pericardial friction rub, S3 and S4 sounds?
Name three pulses you check in a cardiac assessment
What are radial, posterior tibial, dorsalis pedal, and apical?
What three orientation questions do you ask to assess mental status?
DOUBLE JEOPARDY!
What is do you know what day/year/month it is, where are you right now, and what is your name?
Difference between subjective and objective data
DOUBLE JEOPARDY!
What is what the patient feels, experiences; and what I as the nurse see and evaluate?
List three clinical conditions that cause a patient to have tachypnea
What are: asthma attack, respiratory distress, panic attack, RSV, pneumonia, pain?
Name three types of oxygen delivery systems
What is nasal cannula, non-rebreather, venturi mask, CPAP, BiPap, and trach?
Do a full focused Neuro assessment on someone in the class.
What is checking for cranial nerves, motor, sensation, gait, and mental status?
Elements of a health history
What are name, contact information, allergies, DOB, gender, race, relationship status, medical history, surgical history, current medications, family history, employment status, insurance, emergency contact, and advanced directives?
What VS do you want to monitor while performing trach care?
What is O2 saturation?
Normal capillary refill
Auscultate lung sounds in all required lobes on someone.
DOUBLE JEOPARDY!
Auscultates 4 anterior and 2 lateral, then 6 posterior. Starting at top and working your way down. Back goes from narrow, wider, to widest.
Name 3 diseases/conditions that can cause right sided abdominal pain (RUQ and RLQ).
What is appendicitis, gallstones, GI ulcers, IBS, hernia, inflammed gallbladder, liver disease/cancer, pancreatitis?
Order of examination for GI
What is inspecting, auscultating, palpating
What do you do after placing the patient in the correct position and applying a pulse oximeter when doing trach care?
What is increase supplemental oxygen and verify suctioning is working?
Definition of PERRL
What is pupils equal, round, reactive to light
Perform a focused cardiac assessment on someone in the class.
What is auscultate S1 and S2, check pulses, check color/temp/sensation of skin, check for edema, capillary refill?
Do a focused GI assessment on someone in the class.
What is inspect the abdomen, auscultate bowel sounds, and palpate the abdomen?