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Assessment

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  1. Assessment CHAPTER 12 N.F.

  2. Purpose of Assessment • Is the systematic examination of the body • Assessment is the 1st step in the Nursing Process • It’s a method of gathering objective data about your pt

  3. Physical Assessment • Can also help to detect early signs of developing health problems • It establishes a baseline for future comparisons • It allows for evaluation of the pt’s response to medical and nursing interventions • Physical Assessment uses all the senses except taste

  4. Focused Assessment • While performing a whole body assessment, the nurse can look closer at specific parts of the body to gain more needed information • For example, if a pt states that he has tingling in his left foot, the nurse can further test the nerves in that area and try to be more specific as to why the pt has tingling. She understands that nerves may be related, she is using a more holistic assessment

  5. Gathering Information About The Patient • 1. Nurses must 1st obtain a health history – we need to get all past surgeries, medications, conditions in order to eventually treat the person as a whole • 2. We need to obtain personal data such as address, who the pt lives with, emergency contact numbers and names, religion. All of this will help to add to the person’s health history, so we can treat the whole person

  6. Gathering Info. • 3. Ask why the pt is here and ask what their symptoms are • 4. Family hx, this may help us answer questions about current medical condition • 5. Life styles and habits may also tell us info. That will aid in planning for the outcome and care of the pt, do they have help at home, who will assist with insulin, does the pt have health ins. To have homecare nurse come to the house

  7. Gathering Info. • 6. Along with current signs and symptoms…we need • Vital signs, wt and ht

  8. Signs & Symptoms • SIGNS are what others observe – this is objective • SYMPTOMS are what the pt states - this is subjective

  9. Prodromal signs & symptoms • Prodromal – pertains to the initial stage of a disease; the interval between the earliest symptoms and the appearance of a rash or fever • Prodromal S&S are noticed before an illness is obvious

  10. Vital Signs • As part of physical assessment, we always obtain a set of vital signs before we start assessing the physical body • T – P – R – BP- Pain • *****(remember the norms) • Pain is now the 5th vital sign

  11. Temperature • Remember to use the blue tip for oral and the red tip for rectal • Always apply a sheath onto the tip for pt protection • Always use surgical lubricant on the tip of a rectal thermometer • Normal temp: 36.4 – 37.7 • 38.0- eyebrows 38.5 – febrile call Dr.

  12. Pulse • Heart rate • Listen to the apical heart beat for 1 full minute • Normal HR for adults – 60-100 • Normal HR for newborns - 120-160 • Can use other sites for pulse rate, radial is most popular

  13. Respiratory Rate • Normal rate is 12-20

  14. Blood Pressure • Remember to use the correct sized cuff • Normal B.P. – 120/80 • Pressure that needs medication – 150/90

  15. Postural Hypotension (AV)

  16. 4 Basic Physical assessment Techniques • These have been discussed in Skills Lab • 1. Inspection • 2. Percussion • 3. Palpation • 4. Auscultation

  17. Inspection • Most frequently used assessment • Need time, good lighting and you must know the norms of a pt. • It involves examining particular parts of the body, many senses are used to scan the pt

  18. Percussion • The least used Nursing Technique • Drs. use this more, mass is dull or over the liver, lungs and abdomen are air filled and hollow • This technique is when you strike or tap a part of the body with the finger tips to produce vibratory sounds. The quality of the sound aids in determining the location, size and density of underlying structures

  19. Palpation • Is lightly touching or applying pressure • Palpations provides info, about: • Size, shape and consistency and mobility of normal tissue, skin temp, tenderness if any • Pt should be relaxed , warm hands, short nails, gentle touch

  20. Skin Temperature (AV)

  21. Auscultation • Listening to body sounds, is a frequently used assessment technique • We auscultate heart, lungs and abdomen • A stethoscope is required • We also listen to bowel sounds of the G.I. Tract • Must not have much background noise or sounds will be misinterpreted

  22. There are 2 ways to assess your pt • 1. A nurse can use the head-to-toe approach • - Or - • 2. The body systems approach • Either system works and you should pick one that you like and ALWAYS use the same approach as to not forget a system

  23. Sensory • You are trying to get information on the appearance and function of sense organs plus a mental response • You are looking at the eyes, ears, nose, mouth…also the skin, oral and nasal mucous membranes, hair and scalp

  24. Opthalmoscope

  25. Ears • Should contain a small amount of soft cerumen. • Blood or clear spinal fluid should not be present • Some people produce larger amounts of cerumen than others

  26. Ears • Pts may experience tinnitus – ringing in the ears • Can be caused by otis media (ear infection) or by impacted cerumen. May also be caused by medications like an overdose in Tylenol

  27. Mental Status • You are trying to determine the level of a pts cognitive functioning, this is: • Concentration • Memory – ask pt what the day and date are and who is the president…easy questions • For most pts, documenting that the pt is alert and oriented is all that is necessary, check if they are A&O x3 (this is to person, place , time)

  28. If pt is… • A head injury pt • Were recently resuscitated • Were recently confused • Took an overdose • Have a hx of alcoholism or • Have a psych diagnoses • Then more objective info is needed from you. They may not be able to tell you things or answer your questions, you must just observe this

  29. Neuro checks • Determines a patient’s mental status • Besides checking pupils and mental status (A&O x 3), must check motor skills like sticking out of tongue and moving it, and check grasp strength • Have pt squeeze your fingers to determine how strong they are and if the strength is equal on both sides • Have pt push and pull with legs and feet • Have pt move around room, walking to check their gait or mobility and walking, is pt unsteady?

  30. Sternal rub – make a fist and gently but firmly, rub up and down briefly using knuckles. If pt is conscious, he will awaken immediately What to do if pt is not waking up or you want to be certain they are unresponsive?

  31. Muscle strength (AV)

  32. Gait • You want to see if pt can walk and how steady they are on their feet

  33. Gait (AV)

  34. Speech • Some pts can’t speak well, as part of the neurological assessment, speech must be assessed • If stroke or brain damage has occurred, pt may have aphasia… • Next slide for def. of aphasia

  35. Aphasia • Absence or impairment of the ability to communicate through speech, writing, or signing because of the brain’s dysfunction

  36. Expressive Aphasia (AV)

  37. Hair • Inspect the hair for lice or scalp lesions

  38. Assessment of hair includes… • Scalp • Eyebrows • eyelashes

  39. Vision - Eyes • You are looking at the external structure and appearance of the eyes • Is the pupil round and responsive • Is there discoloration, crusting, tearing, swelling, secretions or bilateral movement? • You will chart PERRLA … • PERRLA is…

  40. PERRLA • Pupils Equally Round and Reactto light • andaccomodation • which is the ability to constrict when looking at a near object and dilate when looking at an object in the distance

  41. Pupil Response to Light (AV)

  42. Retina