5 MINUTE ASSESSMENT Arthur Cantos RN, MAN American Dream Review Institute Inc.
WHY DO YOU NEED TO PERFORM ASSESSMENT American Dream Review Institute Inc.
THE 5 STEP NURSING PROCESS Step 1: Assessment Complete data? Lab & x-ray? Multidisciplinary? What is going on? What are my patient’s Learning needs? Step 2: Diagnosis Potential Problems? Top 2 Priorities? Two Measurable Outcomes? Step 5: Evaluation Make a Difference? Modify Plan? Accomplish Outcomes? Step 3: Planning What Shall I do? Interdisciplinary? Resources and Timeline? Not Just Technical Care Involve Patient and Family? Step 4: Implementation Am I Being Effective? Efficient? Have I Delegated Properly?
Your Patients for the day • Mr. Puso, 52 y/o male patient of Dr. Nerva, Left sided CHF with pulm edema, CAD and angina • Mrs. Asukar, 65 y/o female patient of Dr. Tormes, long-term Type I diabetic, admitted for episode of hypoglycemia yesterday • Mr. Baga, 70 y/o chronic COPD of Dr. Dy, admitted for dyspnea episode 2 days ago • Mrs. Tiyan, 45 y/o s/p exploratory laparotomy of Dr. Espiritu, yesterday afternoon • Waiting for new admission from PACU – Mr. Bahag-Hari, s/p suprapubic prostatectomy of Dr. Sy.
It’s Showtime !!! Lights Camera action American Dream Review Institute Inc.
INTRODUCTION • Knock • Greetings • Introduction • Introduce self and members of the team • Identification and role / function • Purpose of assessment • Provide privacy • Plan of Care American Dream Review Institute Inc.
Perform • Wash hands 6. Vital SignsPulse Rate, Strength, Regularity Temperature________ Oral, Rectal, Tympanic Respiration_______________ B / P_________ Pain Assessment _________________ Oxygen saturation ________________
Head to Toe - Neuro • Orientation – time, person, place, reasonWhat year is this ? ________________________Tell me your name ? _______________________Tell me where you are ? ____________________Tell me why you are here?__________________ • Pupil Check ( PERRLA ) Pupils, Equal, Round, React to light, AccommodateSluggish ( ) No Change ( ) Brisk ( ) Normal ( )Accommodation Yes ( ) No ( ) Free Template from www.brainybetty.com
Mr. Puso American Dream Review Institute Inc. Mr. Puso, 52 y/o male patient of Dr. Nerva, Left sided CHF with pulm edema, CAD and angina 11
Landmarks American Dream Review Institute Inc.
Cardiac • Neck VeinsPatient at 45 degree angle ( )Neck Veins Flat ( ) Distended ( ) • Heart TonesApical Pulse with StethoscopeRate ?_____________ Rhythm ? ___________Clarity of Sounds ? _________ Abnormal ? ( )Explain ! ____________________________
Heart Tones Heart tones are checked by listening to the apical pulse. This pulse is auscultated with the bell of the stethoscope. Check the apical pulse for rate, rhythm, and clarity of the sounds of the S1 and S2 otherwise known as "lub and dub". Any abnormalities should be reported.
Heart Sounds Heart sounds result from the vibrations from closure of the heart valves and the acceleration and deceleration of blood flow. • S1 - the lub sound that represents closure of the tricuspid and mitral valves. Heard best at the apex. • S2 - the dub sound. This represents closure of the aortic and pulmonic valves. It is the onset of ventricular diastole and is heard best at the aortic area. • S1 split - a slight difference in valve closure timing. This is a normal variation heard best at the right 4th intercostals space.
Heart Sounds • S2 split - this is a splitting of the dub, or the second sound. Heard best during inspiration at the pulmonic area. Usually disappears in the sitting position • S3 (ventricular gallop) - normal in healthy children and young adults and is produced by vibrations of the ventricles due to rapid distention. This may be seen in left ventricular failure. Heard best at the apex with the patient lying on the left side. Heard with the bell of the stethoscope and sounds like “Kentucky”. May indicate incompetence of the mitral and tricuspid valves. S1 S2 S3 Ken tuck ee Lub dub dub
Heart Sounds S4 (atrial gallop or presystolic gallop) - Heard best over the apex with the pt in lying supine. Indicative of increased resistance to filling and may be associated with coronary artery disease, hypertension, aortic stenosis, or the elderly. This sound is heard best with the bell of the stethoscope over the left lower sternal border. It sounds like “Tennessee”. S4 S1 S2 Ten ne see Dub lub dub
Heart Sounds Classifications • Diastolic Murmurs - occur between S2 and S1. Seen in mitral or tricuspid stenosis, aortic or pulmonic insufficiency. • Systolic murmurs - occur between S1 and S2. Seen in aortic or pulmonic stenosis or mitral or tricuspid insufficiency. They are also called holosystolic or parasystolic murmurs.
Heart Sounds Heart Murmurs - are caused by increased flow through normal structures. Areas for Auscultation Mitral murmurs are heard best with the patient in the left lateral position. Aortic murmurs are heard best with the patient sitting and leaning forward after complete exhalation. American Dream Review Institute Inc.
Cardiac • Bilateral Checks • ( Radial Pulses ) - Rate, Strength, RegularityRight_____________ Left______________ • ( Hand Strength ) - 2 fingers onlyRight Stronger ( ) Left Stronger ( ) Equal ( ) • ( Pedal Pulses – DP/PT ) - Top of FootRight Foot __________ Left Foot ____________ • ( Capillary Refill ) - On fingers or toes 3 seconds or lessRight Fingers ( ) sec. Left Fingers ( ) sec. Right Toes ( ) sec. Left Toes ( ) sec. American Dream Review Institute Inc.
Mr. Baga Mr. Baga, 70 y/o chronic COPD of Dr. Dy, admitted for dyspnea episode 2 days ago 21
Landmarks American Dream Review Institute Inc.
Pulmonary 12. Breath Sounds • Assess anterior and posterior and from side to side, left to right lobe. • Have patient take deep breaths, do not move stethoscope to rapidly to avoid hyperventilating on patients part. • Clear Bilaterally ( ) Left only ( ) Right only ( )diminished, tight bilaterally ( ) • Crackles or Rales, Fine or Coarse Crackles, Rhonchi • Good air flow ( ) Poor air flow ( ) • ICSP __________ American Dream Review Institute Inc.
Breath Sounds The diaphragm of the stethoscope is used for assessing breath sounds. The right middle lobe is assessed by listening on the patient's right side. Have the patient take deep breaths in and out of their mouth. Nose breathing can create air turbulence that may alter the sounds. Breath sounds should be clear bilaterally with good air flow. American Dream Review Institute Inc.
Breath Sounds Normal breath sounds • Bronchial sounds - Pitch: High. Intensity: Loud, predominantly on expiration. Normal findings: A sound like air blown through a hollow tube • Bronchovesicular sounds - Pitch: Moderate. Intensity: Moderate. Normal findings: A blowing sound heard over airways on either side of sternum, at angle of Louis, and between scapulae • Vesicular sounds - Pitch: High on inspiration, low on expiration. Intensity: Loud on inspiration, soft to absent on expiration. Normal findings: Quiet, rustling sounds, heard over periphery American Dream Review Institute Inc.
Breath Sounds Abnormal breath sounds - diminished, distant or tight • Bronchial sounds - Pitch: High. Intensity: Loud, predominantly on expiration. Normal findings: A sound like air blown through a hollow tube • Bronchovesicular sounds - Pitch: Moderate. Intensity: Moderate. Normal findings: A blowing sound heard over airways on either side of sternum, at angle of Louis, and between scapulae • Vesicular sounds - Pitch: High on inspiration, low on expiration. Intensity: Loud on inspiration, soft to absent on expiration. Normal findings: Quiet, rustling sounds, heard over periphery American Dream Review Institute Inc.
Breath Sounds ADVENTITIOUS SOUNDS • Crackles (Rales)Where to auscultate: Over lung fields and airways; heard in lung bases first with pulmonary edemaTiming:More obvious during inspirationCause: Moisture, especially in small airways and alveoliDescription: Light crackling, bubbling; nonmusical • Rhonchi (Gurgles) and Coarse CracklesWhere to auscultate: Over larger airwaysTiming: More pronounced during expirationCause: Airways narrowed by bronchospasm or secretionsDescription: Coarse rattling, usually louder and lower-pitched than crackles; described as sonorous, musical. Rhonchi typically clears with coughing.
Breath Sounds • WheezesWhere to auscultate: Over lung fields and airwaysTiming: Inspiration or expirationCause: Airways narrowed by bronchospasm Description: described as sonorous, musical, or sibilantCreaking, Whistling; high-pitched, musical squeaks • Pleural Friction RubWhere to auscultate: Front and side of the lung fieldTiming: InspirationCause: Inflamed parietal and visceral pleural surfaces rubbing together.Description: Grating or squeaking
Neck Veins Neck veins should be checked by having the patient sit at a 45 degree angle. In this position, the jugular veins should be flat. Distended neck veins at 45 degrees are an indicator of over hydration or fluid overload. American Dream Review Institute Inc.
Mrs. Tiyan American Dream Review Institute Inc. Mrs. Tiyan, 45 y/o s/p exploratory laparotomy of Dr. Espiritu, yesterday afternoon 31
Gastro-intestinal • Bowel Sounds • Assess all 4 quadrants, do not touch stomach before auscultation, as it may disrupt normal sounds. If irregular, • 1 minute assessment on each quadrant. Umbilicus is mid point. • ( Stomach ) - Check for conditionSoft ( ) Hard ( ) Distended ( ) Other • RUQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( ) • RLQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( ) • LUQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( ) • LLQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( ) Free Template from www.brainybetty.com
Mr. Bahag-Hari American Dream Review Institute Inc. Waiting for new admission from PACU – Mr. Bahag-Hari, s/p suprapubic prostatectomy of Dr. Sy. 35
Genito-urinary • Ask the patient Urgency, Burning, Incontinence, pain • Assess Catheter, Drainage, Urine output
Mrs. Asukar Mrs. Asukar, 65 y/o female patient of Dr. Tormes, long-term Type I diabetic, admitted for episode of hypoglycemia yesterday 38
Integumentary • Skin • Skin Turgor - 1 to 3 second return, on SternumReturn was ( ) sec. Abnormal ( ) sec. • Skin Color - Check on inside of Lip or ConjunctivaLip ( ) Conjunctiva ( )Pink ( ) Pale ( ) Jaundice ( ) Cyanotic ( ) • Skin Temperature - Use back of hand to checkHot ( ) Warm ( ) Cool ( ) American Dream Review Institute Inc.
Braden Scale 17. Skin Breakdown Check
Peripheral Edema Edema, or fluid in the tissues tends to go to dependent areas of the body. This may be the hands, feet or sacrum. For the bed rest patient, the dependent area is most often the sacrum. To check for edema push your finger down on the feet, hands, and sacrum. Observe for indentation or pitting. American Dream Review Institute Inc.
ASSESSMENT SCALE FOR PITTING EDEMA 1+ slight pitting, no visible distortion, disappears rapidly 2+ somewhat deeper pit than 1+, no readily detectable distortion, disappears in 10-15 sec. 3+ pit noticeably deep, may last more than a minute; the dependent extremity looks fuller and swollen. 4+ pit very deep, lasts 2-5 min; dependent extremity is grossly distorted.
Vascular • Peripheral Edema • Edema is found in dependent areas such as the feet, hands, sacrum. Check with finger by pressing down. • Observe for pitting or indentation.Feet Yes ( ) No ( ) Pitting ( ) R ( ) L ( )Hands Yes ( ) No ( ) Pitting ( ) R ( ) L ( )Sacrum Yes ( ) No ( ) Pitting ( ) Indent 19. Distal Pulses • Dorsalis Pedi and Post Tibial • Palpable or dopplerable • Arterial or venous
Post Tibial DorsalisPedis
Vascular • Homan's SignAsk patient to dorsiflex both feet.Pain in right calf Yes ( ) No ( )Pain in both calves Yes ( ) No ( )
Pain Assessent • Assessing For Pain (PQRST method) P – Provokes, palliative measure Q – Quality (describe) R – Region, radiate? S – Severity, on a scale of 0 - 10 T – timing, when did it start? How long does it last?
Psychosocial • Psychosocial Aspects • Affect of illness on role such as work, family • Inappropriate independence, dependence? • Check for depression, suicidal ideation if needed. American Dream Review Institute Inc.
Education Assessment • Response to learning Learning barriers
Closure 24. ClosureLet the patient know you are finished and when you will be back. • Bedrails up ( ) • Bed in low position ( ) • Call light in reach ( )
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