SOAP modified format - ANSWER Subjective
Objective
Assessment
Plan
What color ink should be used when documenting on paper - ANSWER Permanent
black ink
What is the correct order for vital signs - ANSWER T, P, RR, BP, extremity, pt
position, SPO2
What should be at the top of every page of documentation - ANSWER Patient
initials and date and time of entry
What should be at the end of every documentation entry - ANSWER Interviewers
signature
How do you correct a mistake in documentation - ANSWER 1) Draw a single line
through the incorrect documentation
2) Write error above the entry
3) Initial and date the crossed out entry
Documentation tips - ANSWER 1) Avoid complete sentences
2) Do not use A, an, the
3) Do not put opinion in notes
4) Avoid use of normal or within normal limits
Normal oral temp range - ANSWER 96.4 - 99.1 F
Febrile - ANSWER With fever
Afebrile - ANSWER Without fever
Hyperthermia symptoms - ANSWER 1) Cessation of shivering
2) Bradycardia
3) Decrease in respiratory minute volume
Most common and easy method of assessing temperature - ANSWER Oral
What methods of assessing temperature reflects core temperature - ANSWER 1)
Oral
2) Rectal
3) Tympanic
4) Temporal Artery
What is the least accurate method of assessing temperature - ANSWER axillary
Which patients are contraindicated for rectal temperature readings - ANSWER
Patients with increased HR
,Preferred method of taking infants and small children's temperatures - ANSWER
Rectal
Pulse deficit - ANSWER - Difference between apical peripheral pulse
Pulse amplitude scale - ANSWER 0 = no pulse
1 = diminished, weak
2 = normal and expected
3 = full or strong
4 = bounding
Which pulses are assessed during a routine physical assessment? - ANSWER 1)
Apical
2) Radial
3) Dorsalis pedis
4) Posterior tibialis
Normal heart rate in resting adult - ANSWER 60 to 100 bpm
Well trained athletes heart rate - ANSWER Heart rate less than 60 bpm
When is it normal for someone to have a rapid heart rate over 100 bpm - ANSWER
Someone with anxiety and right after exercise
Eupnea - ANSWER Normal RR, rhythm and depth
Normal SPO2 value - ANSWER 95-100%
What level is poor oxygenation - ANSWER below 90%
Systolic BP - ANSWER Maximum pressure on the artery during ventricular
contraction
Diastolic BP - ANSWER Resting pressure during ventricular filling
Pulse pressure - ANSWER Difference between systolic and diastolic
Stroke volume - ANSWER Amount of blood ejected with each beat
How does age affect BP - ANSWER BP increases with age
What BP is pre hypertensive? - ANSWER Sustained BP over 120/80
What extremities should you avoid taking a BP in - ANSWER Extremities with IV
lines, invasive lines, history of mastectomy/lymph node issues
Orthostatic hypertension - ANSWER - Decreased BP with change in position
- Drop in SBP of 25 mmHg or DBP of 10 mmHG
, - Symptoms
1) Dizziness
2) Weakness
3) Blurred vision
4) Syncope
5) Changes in BP/HR
- Causes
1) Hypovolemia
2) Impaired vasoconstriction
3) Medications
Precautions in someone with orthostatic hypertension - ANSWER - change
positions slowly
- falls risk
- assist back to bed if symptomatic
What is the main objective of the health history - ANSWER - To gather accurate
information to provide immediate care
- Establish rapport with the client
What does establishing a positive patient relationship depend on - ANSWER 1)
courtesy
2) comfort
3) connection
4) confirmation
5) confidentiality
What questions should you begin with for a health history interview - ANSWER
Open ended questions
Approaching Sensitive Issues - ANSWER - Use language that is understandable.
- Do not apologize for broaching the issue.
- Ensure privacy.
- Be direct and firm.
- Do not preach.
- Do not push too hard.
CAGE questionnaire - ANSWER Cutting down
Annoyance
Guilty feeling
Eye-openers
- Helps diagnose alcoholism
TACE questionnaire - ANSWER T - how many drinks does it TAKE to make you
feel right
A - Have people ANNOYED you by criticizing your drinking
C - Have you felt you out to cut down on your drinking
E - Have you had an EYE -OPENER first thing in the morning
Objective
Assessment
Plan
What color ink should be used when documenting on paper - ANSWER Permanent
black ink
What is the correct order for vital signs - ANSWER T, P, RR, BP, extremity, pt
position, SPO2
What should be at the top of every page of documentation - ANSWER Patient
initials and date and time of entry
What should be at the end of every documentation entry - ANSWER Interviewers
signature
How do you correct a mistake in documentation - ANSWER 1) Draw a single line
through the incorrect documentation
2) Write error above the entry
3) Initial and date the crossed out entry
Documentation tips - ANSWER 1) Avoid complete sentences
2) Do not use A, an, the
3) Do not put opinion in notes
4) Avoid use of normal or within normal limits
Normal oral temp range - ANSWER 96.4 - 99.1 F
Febrile - ANSWER With fever
Afebrile - ANSWER Without fever
Hyperthermia symptoms - ANSWER 1) Cessation of shivering
2) Bradycardia
3) Decrease in respiratory minute volume
Most common and easy method of assessing temperature - ANSWER Oral
What methods of assessing temperature reflects core temperature - ANSWER 1)
Oral
2) Rectal
3) Tympanic
4) Temporal Artery
What is the least accurate method of assessing temperature - ANSWER axillary
Which patients are contraindicated for rectal temperature readings - ANSWER
Patients with increased HR
,Preferred method of taking infants and small children's temperatures - ANSWER
Rectal
Pulse deficit - ANSWER - Difference between apical peripheral pulse
Pulse amplitude scale - ANSWER 0 = no pulse
1 = diminished, weak
2 = normal and expected
3 = full or strong
4 = bounding
Which pulses are assessed during a routine physical assessment? - ANSWER 1)
Apical
2) Radial
3) Dorsalis pedis
4) Posterior tibialis
Normal heart rate in resting adult - ANSWER 60 to 100 bpm
Well trained athletes heart rate - ANSWER Heart rate less than 60 bpm
When is it normal for someone to have a rapid heart rate over 100 bpm - ANSWER
Someone with anxiety and right after exercise
Eupnea - ANSWER Normal RR, rhythm and depth
Normal SPO2 value - ANSWER 95-100%
What level is poor oxygenation - ANSWER below 90%
Systolic BP - ANSWER Maximum pressure on the artery during ventricular
contraction
Diastolic BP - ANSWER Resting pressure during ventricular filling
Pulse pressure - ANSWER Difference between systolic and diastolic
Stroke volume - ANSWER Amount of blood ejected with each beat
How does age affect BP - ANSWER BP increases with age
What BP is pre hypertensive? - ANSWER Sustained BP over 120/80
What extremities should you avoid taking a BP in - ANSWER Extremities with IV
lines, invasive lines, history of mastectomy/lymph node issues
Orthostatic hypertension - ANSWER - Decreased BP with change in position
- Drop in SBP of 25 mmHg or DBP of 10 mmHG
, - Symptoms
1) Dizziness
2) Weakness
3) Blurred vision
4) Syncope
5) Changes in BP/HR
- Causes
1) Hypovolemia
2) Impaired vasoconstriction
3) Medications
Precautions in someone with orthostatic hypertension - ANSWER - change
positions slowly
- falls risk
- assist back to bed if symptomatic
What is the main objective of the health history - ANSWER - To gather accurate
information to provide immediate care
- Establish rapport with the client
What does establishing a positive patient relationship depend on - ANSWER 1)
courtesy
2) comfort
3) connection
4) confirmation
5) confidentiality
What questions should you begin with for a health history interview - ANSWER
Open ended questions
Approaching Sensitive Issues - ANSWER - Use language that is understandable.
- Do not apologize for broaching the issue.
- Ensure privacy.
- Be direct and firm.
- Do not preach.
- Do not push too hard.
CAGE questionnaire - ANSWER Cutting down
Annoyance
Guilty feeling
Eye-openers
- Helps diagnose alcoholism
TACE questionnaire - ANSWER T - how many drinks does it TAKE to make you
feel right
A - Have people ANNOYED you by criticizing your drinking
C - Have you felt you out to cut down on your drinking
E - Have you had an EYE -OPENER first thing in the morning
