sandanrn

Jesus meets Martial Arts meets Nursing School

LONG POST – what I did for homework

Here is what I typed up to study by. It is the BASICS of doing an assessment. These are required when a patient first arrives at the facility. This is known as an Initial Assessment. Should be completed in 15 minutes or less! OMG! Happy reading, and I understand if you choose to skip this post! lol — sandanrn

 

Assessment

Equipment: BP cuff, stethoscope, thermometer, pen light, tongue depressor, tape measure, reflex hammer, clean gloves, scale, alcohol swab, cotton ball, wrist watch, draping

 

Remember:

  1. Inspect
  2. Palpate
  3. Percussion
  4. Auscultation

 

Except abdomen which is look, listen, feel.

v  Introduction

  • Knock
  • Enter Room
  • Introduce self
  • Explain procedure.
  • Wash hands (ask how they are doing and if feeling any pain. Address this first.)
  • Ask if they need to void before beginning assessment.

 

v  Health History

  • Medications
  •  Allergies to medication or food
  •  Past surgeries
  • Medical Problems
  • Family History
  • Alcohol, Cig, Drug Use
  • Recent Falls (Fall Risk)
  • Belongings (DOCUMENT the path every belonging takes ie. To safe, home with relative, etc.)

 

v  General Survey

  • Vital Signs
  • temp (thermometer)
  • pulse (wrist watch)
  • respirations
  • bp (sphygmomanometer)
  • pain (follow-up)
    •  Height and Weight (tape measure, scale)
    •  Racial or ethnic variations

 

v  Psychosocial Status (affects physical recovery)

  • How do you feel?
  • Any recent changes?

 

v  Neurological System

  • Level of consciousness – are you alert?
  • Orientation (oriented x3)
    • name?
    • year, who is president?
    • where are you?
    • Language
      • voice clear?
    • Memory

¨       STM (paper, pencil, pen… explain for them to remember the words because you will ask them to repeat later)

¨       LTM (birthdate)

  • Affect

¨       looking for congruency between mood and affect

  • Motor Function

¨       -flacid (can be moved, but you have to move it for them)

¨       contracture (rigid, fixed in place)

  • Sensation  (cotton ball, alcohol swab)

¨       upper and lower extremities on both sides for dull (cotton ball) and sharp (corner of alcohol swab packaging) sensation

 

*** ASK WHAT STM WORDS WERE ***

Strength (use only 2 fingers for safety!)

¨       -squeeze with each hand

¨       press against hands with hands and feet (gas pedal)

 

 

MAKE SURE BED IS AT APPROPRIATE HEIGHT

 

 

 (HEENT – head eyes ears nose throat/mouth)

  • Head

¨       scalp (dandruff)

¨       hair (thinning)

  • Eyes (PERRLA: pupils equal, round, reactive to light, accommodation) (pen light)

¨       accommodation- focus on near then far object, pupils should dilate

  • Ears

¨       Whisper Test (stand behind client and whisper word behind each ear)

¨       Insp- Look at

¨       Palp- temperature, pain, tenderness

  • Nose

¨       Insp- symmetry to face and side to side, drainage, incrustations (boogers), deviated septum, see if nares are patent/open.

¨       -Palp- occlude each nare and check for patency, sinuses for tenderness

Throat/Mouth

  • trouble swallowing? Thin/thick liquids?
  • -Insp- midline, drooping, color, sores, dryness, cryptic tonsils, uvula, tonsils, frenulum of tongue midline
  • -JVD- Jugular Vein Distinction – is it showing? (JVD is negative if you don’t see it.)

        Coratid- graded 1+, 2+, 3+ (quality of pulse, both sides), check for bruit (squishing sound)

 

         Oral Mucosa (tongue depressor)

  • -flacid (can be moved, but you have to move it for them)
  • contracture (rigid, fixed in place)

 

 

Integumentary System

DANGER SIGNS FOR CANCER ARE A.B.C.D.- Asymmetry, Border irregular, Color varied, Diameter >eraser

  • 1.Intact (clean and free from odor)
  • 2. Skin Color (pale/pallor, blue/cyanosis, red/erythemia, yellow/jaundice)
  • 3. Edema (pitting or nonpitting)
  • Turgor (check inferior to clavicle on older pt.)

¨       pull gently on back of wrist and see if skin returns or is “tenting”

  • Lesions: alteration from normal

¨       If found:

  • -document location and size

¨       look for drainage

Nail Assessment (free of polish and acrylics)

  • insp- lines, beau’s line, capillary refill ❤ sec.
  • Rashes
  • Temperature (esp. at joints)

 

v  Cardiovascular System (stethoscope)

  • Insp- short of breath?
  • Palp- for tenderness
  • Ausc-
    •  is it regular pulse or irregular? Any addt’l sounds?
    • A Point To Memorize!

¨       Aortic (S1 louder) – right sternal border, 2nd intercostal space

¨       Pulmonic (S1)- left sternal border, 2nd intercostal space

¨       Tricuspid(S2)- left sternal border, 4-5th intercostal space

¨       Mitral (S2)- mid clavicular line, 5th intercostal space

  • Count apical pulse for one full minutE

 

 

v  Respiratory System (stethoscope)

Insp- short of breath?

  • Check for diaphragmatic excursion (put thumbs together on spine, they should sep. approx. 5cm during inhalation and go back together at exhalation)
  • Check for tactile fremitus (put hands behing lungs and have them say “99” to see if vibrations are congruent)
  • Palp- for tenderness
  • Ausc-
    • What sounds are present?

¨       NORMAL

  • Bronchiole (neck area)
  • Bronchovascicular (near clavicle)
  • Vasicular (everywhere else)

¨       ADVENTITIOUS (Abnormal)

  • Crackles
    • Coarse (thick paper rubbing together)
    • Fine (record player popping, higher pitch)
    • Wheezing (tightening of airways)
    • Rochi (gurgles) – sounds like ppl talking in adjacent room (fluid)
    • Stridor (partial block of airway)

¨       ABSENT

  • Worsened closing of airway
  • FATAL if left untreated

 

 

v  Breast Exam

Insp- lumps and tenderness

                – raise arms and lower (looking for changes in swelling or nipples)

                -palms together and push (looking for retraction)

                – extend arm up and hand behind head, pillow under shoulder so breast is flat

                                – move in circular, star, or up and down pattern palpating for masses/pain

 

 

v  GI System (stethoscope) LOOK,LISTEN,FEEL!

  • Ask : passing stools regularly? When was last stool? Any pain?
  • Insp- symmetry, skin integrity, distension (bloated)
  • Check abdominal girth at umbilicus (tape measure)
  • Ausc- bowel sound in all four quadrants

¨       <5 hypoactive

¨       5-30 normal

¨       >30 hyperactive

  • Palp- for tenderness, lumps, or lesions

 

v  Genitourinary System

  • Urinary Output
    • Color, amount (30cc/hr), frequency
    • Continence
    • Catheter (is it draining urine)
    • Ask : passing stools regularly? When was last stool? Any pain?
    • Insp- symmetry, skin integrity
    • Palp- tenderness, distension (bloated)

Genitalia

                Insp- symmetry, rashes, odor, drainage

                Palp- tenderness, lumps, lesions

 

v  Musculoskeletal System

  • ROM
    • Full or limited?
    • Passive(you do it), Active (they do it)
    • Strength, Sensation
    • Termperature (warmth of joints)
    • Insp- edema, symmetry, tremors, deformities, color, bruises, rashes
    • Circulation/ Neurovascular Checks –IMPORTANT
    • Lesions, lumps
    • Pain,crepitus
    • Reflexes
    • Homan’s Sign (pull foot toward head, major pain in back of calf)
Advertisements

Single Post Navigation

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: