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44 Cards in this Set
- Front
- Back
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What does an Assessment involve ? |
*Comprehensive: physical, mental, spiritual social economic & cultural *Nursing history & physical exam |
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NSG Assessment |
Patients functional abilities & physical responses |
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Medical Assessment |
disease & pathology |
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Physical Exam |
Both Subjective & objective |
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Why do we assess a PT ? |
* obtain a baseline * identify nursing diagnoses * monitor status * screen for health problems |
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Different types of Assessment? |
* inpatient (comprehensive) vs ED (focused) * system- specific - focused exam limited to (1) body system * ongoing assessment - after initial baseline is completed & happens w/ every interaction w/ PT |
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How do I do an Assessment ? |
* develop head-to- toe system approach to use every time *Know equipment, techniques, & AP *Prepare what you use before hand but be mindful of how it looks to enter room *PT is covered, drapes closed * maneuver PT *look PT in eyes & know cultural differences |
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Positioning the PT Supine Dorsal Recumbent Lithotomy Sims Prone Lateral Recumbent Knee- Chest |
Supine- laying on back arms/ legs extended Dorsal Recumbent- Perspine with knees bent Lithotomy- DR w legs in stirrups & spread wide Sims- laying on side (1) leg flexed to chest Prone- laying on stomach Lateral recumbent- laying on side straight Knee- chest- on hands/ knees butt in air |
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Order of Assessment ? |
* Inspection * Palpation*Percussion * Auscultation Except Abdomen- * inspection* Auscultation* Percussion * Palpation Palpating can cause pain & sounds |
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Inspection |
* done at visually * Starts at door * On PT level * Window access all PT to prioritize - Skin - Position - breathing - environment - alertness |
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Palpation |
* use of touch for temp, skin, moisture, abnormalities, area of tenderness * don't use thumbs * light touch 2 fingers *use back of hand to check temp *do pain area last * tell PT before you touch them be gentle warm hands |
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Percussion |
* tapping fingers using short strokes * producing vibration to determine location, size & density of structures |
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Auscultation |
* using hearing to listen * stethoscope - Diaphragm- used on high pitched sounds of heart lungs belly - Bell - low pitched sounds of murmurs/ brutis * listen to everything at once |
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Olfaction |
* smell to diagnose certain conditions ETOH, DKA, UTI |
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Age Groups & how to access ? |
* infant- parent holding have to do full minute * toddlers- sit in parent lap doing oral /ears last *preschoolers- show them things 1st * school age- ask questions, demonstrate * adolescents- self conscious / Ask sex ?s last * Adults- no issues |
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Older Adults Assessment issues that require interventions |
S- Sleep disorders P- problems eating/ feeding I- incontinence C- confusion E- evidence of falls S- skin breakdown |
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What to check for in a general survey of PT? |
*Appearance & behavior * Speech- illogical, rapid, slow, hoarseness *dress, grooming, hygiene * mental state *vital signs * height & weight |
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Mongolian spots |
*benign, blue black birthmarks that occur on lower back & butt of black, Hispanic, Asian & native Americans fades by 2 |
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Capillary Hemiangiomas |
Stroke bites small irregular pink red areas on face or neck of newborns Disappear in infancy but can last till age 5 |
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Cafe- au- lait spots |
light brown birthmarks that can occur on any part of body |
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Pallor |
paleness lose of color poor circulation or low hemoglobin levels check hands feet mouth & eyes |
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Cyanosis |
Blue gray coloration of skin if seen in lips & mouth associated with hypoxia also seen in extremities exposed to extreme cold |
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Jaundice |
Yellow- orange cast to skin Associated with liver disorders Also known as Icterus |
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Flushing |
widespread areas of redness Associated with fever |
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Ecchymosia |
bruised associated with physical abuse, internal bleeding, side effect of meds |
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Petechiae |
tiny reddish/purple pinpoint spots associated with extravasation leaking of blood into skin |
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Mottling |
bluish marbling Associated with light skinned PTs when they are cold |
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What do you assess on the skin? |
* temp * moisture *texture * turgur - tenting- checks hydration on forearm/ sternum - Edmema- +1 2mm rapid rebound +2 4mm/15 secs +3 6mm/1-2 mins +4 8mm/2-3 mins |
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Lesions : ABCDE |
A- Asymmetry B- border irregular C- color variation D- diameter of .5 cm or more E- Elevation |
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What do you assess for hair ? |
*color *texture *distribution Alopecia vs hirsutism craddle cap |
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What do you assess for Nails? |
*pink nails with rapid cap refill refill less than 3 secs * nail shape( clubbing) *white or yellow spots * pale or cyanotic |
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What do you assess for skull & Jaw ? |
* head size * symmetrical * cracking from TMJ |
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What do you assess for Eyes? |
*PERRLA *visual acuity *color vision *cataracts *strabismus (crossed eyed) *Amblyopia- lazy eye |
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What do you assess for Ears ? |
*ears level with eyes * completes sound transfer to middle& inner *earwax build up * ear drum - Weber test- should hear out of both ears -Rhinne test- compare AC & BC -Romberg test- close eyes and feet together if sway equilibrium problem |
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What do you assess for Head? Nose, Mouth, Neck |
Nose - look using pen light - Should breathe evenly out both sides Mouth - Teeth/ gums- color, sores, swollen - Tongue- deviation form mid line, glosstitis, furry, ulcers, smooth red Neck - thyroid -lymph nodes - asymmetrical head position |
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Why do we assess breast with axillae? |
* to examine lymph nodes next to the tissue for abnormalities * teach importance of mammograms |
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What do you assess for Chest/ Lungs? Sounds and where to locate them? |
* note changes: COPD Kyposis scoliosis * bronchial- loud high pitched tubular heard at the base of neck over trachea *bronchovessicular- medium pitched located either side of the upper sternum equal sounds for inhaling & exhaling *Vesicular- low pitched breezy sounds with long inhale short exhale |
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What are the 2 main networks of the Cardiovascular system |
* pulmonary * systemic |
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PMI |
* point of maximal impluse * same location of apical pulse |
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What do listen for when assessing the Heart and what is happening? |
* S1- LUB low pitched beginning of systole valves b/w aortia & ventricles * S2- DUB higher pitched beginning of diastole closure of semilunar valves |
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What other sounds can be heard when listening to heart and what are they signs of ? |
* S3- heard after S2 gallop - normal in kids & pregnant women - heart failure or volume overload - lower in pitch than LUB DUB *S4- heard before S1 - normal in athletes & older adults - can be heard in CAD, HTN, Plumonic stenosis * murmurs- whoosh produced by turbulent blood flow |
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What do you assess for Abdomen ? |
* assess 4 quadrants inspect/ listen before palpate pain areas last * SF position * if no sounds are heard must listen 5 mins * hypoactive- 1 every min *hyeractive loud rushing sounds |
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What do you assess for musculoskeletal system? What type of ROM is there? |
* consists of bone, muscles, joints & bursae * posture gait bone structure muscle function joint mobility * look for crepitus ( clicking/ grating of joints * Active ROM- Client moves * Passive ROM- You move the PT |
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What do you assess for for neurological system? |
*reflexes * Specialized screen test for kids *level of consciousness *orientation- time place person * mental status- ability to concentrate & answer questions memory |
