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195 Cards in this Set

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Personal Hygiene - Factors influencing Hygiene
Physical condition
Developmental Status
Knowledge Level
Culture
Socioeconomic Status
Social & Religious Practices
Body Image
Personal Preferences
Purposes of Hygiene
Promotes Cleanliness
Provides comfort, relaxation
Improves self-image
Stimulates Circulation
Allows for assessment
Critical thinking & Hygiene
-nurse uses knowledge to give care that provides comfort
-Curiosity & humility-use to assess more fully & to learn client's preferences in care
Questions: what are two critical thinking attributes used in hygiene care for a patient?
curiosity & humility
Comprehensive Assessment
-nurse should examine all skin areas for integrity or breakdown
-nurse can talk to pt about problems or concerns
While performing a comprehensive assessment during hygiene what are two opportunities the nurse has?
to examine
to communicate
Types of Baths
complete
partial
assist
tub
shower
What should be the water temp. when giving a bedbath?
105-115
Oral Care
EXTREMELY IMPORTANT
What is Sordes?
crust or pcs of food and bacteria on the teeth, and about the lips
What is a nosocomial infection?
inborn hospital infection, pay particular attention to cathaters.
What is the most important task when shaving a patient?
chart nicks
wear gloves
When would you not use an electric razor?
when would you not use a blade razor?
around oxygen

pt on anticoagulant
pt that is a hemophiliac
Functions of skin:
protection
regulation of temp
sensation
prod. of vitamin D
secretes Sebum
Normal skin appearance"
variation in pigment
good turgor, smooth, soft flexible
no evidence of cyanosis, jaundice or pallor
warm to touch
intact, no abrasions or excoriations
normal lesions defined by age of individual
List ways to id and describe a lesion:
asymmetry
border
color
diameter
type
shape, arrangement, distribution
Who is at risk for skin impairment?
poor nutritional status
immobility
altered or limited hydration
secretions or excretions on skin
mechanical devices
altered venous circulation
When making a bed what are the 3 conditions you should afford your patient?
Privacy
Safety
Comfort
What is the first step in the Nursing Process?
assessment or gathering and analysis of information about the client's health status
How is the nursing process used?
to identify, diagnose & treat human responses to health & illness
What are the 5 steps of the nursing process?


*
assessment
nursing diagnosis
planning
implementation
evaluation
adpie
First item you need to know in assessment (nursing process)?
what are the pts norms
Subjective/objective
what the pt tells you
what you can see or measure
Types of data needed in the nursing process:
subjective/objective
Methods of data collection:
interview
pt or family members
Nursing Process & critical thinking- what are the attributes of Critical thinking needed for the Nursing Process
Knowledge
Experience
Standards
Attitudes
What are 3 types of Diagnoses?
Actual-characteristics-human responses
Risk- human responses
Wellness- education etc-human responses
What are the components of the Nursing Diagnosis?
1.Diagnostic label-diagnosis
2.Related factors-statement & etiology
3.Definition-describes the human response-actual vs risk
4.Risk factors-all that increase vulnerability of pt
5.Support of diagnostic statement- assessment data
What are the attributes of concept mapping?
1.more integral than care plans
2.incorporates critical thinking
3.developes associative thoughts, links together lines of reasoning
4.more emcompassing picture of pt limitations of nursing diagnosis
5.better understanding of what the diagnosis should communicate
6.imprecise language may "mislabel" a client
What are four attibutes of Planning Nursing Care?
1. establish priorities
2. establish goals & expected outcomes
3.interventions
4.implementation
Questions to ask yourself when planning nursing care
What is going to happen? What do you suspect is going to happen?
What are nursing interventions and implementations?
any treatment, based on knowledge & judgement, that a nurse performs to enhance client outcomes-includes direct & indirect care, continous process, ever-adaptive
How do you use critical thinking in nursing care?
foundation to decision making process
guides care, direction of diagnosis & use of ongoing data collection
supports incorporation of knowledge to delegate, monitor and evaluate care of clients
What is the Evaluation Process in nursing care?

*
one of the most critical phases, ongoing, uses objective and subjective data, determines the effectiveness of nursing care & includes 5 elements
id
evaluate
interpet
Five elements of effectiveness in nursing care:

*
-id criteria & standards
-evaluate data to determine if standards are met
-interpreting & summarizing findings
-documenting findings & clinical judgements
-modifying or terminating, continuing or revising care plan
IEIDM
Identifying criteria & standards:
-nurse evaluates care by knowing what to look for
-goals & expected outcomes must be clealy defined so that the nurse has objective criteria
-goals should be established based on standards of care
-expected outcomes should be goal-oriented & measurable
id
evaluate
interpet
document
modify
-Evaluative Data

*
collected using developed assessment skills & tech.
-data collection should occur over a period of time to determine patterns of improvement or change
-primary source of data is the client
-secondary sources may include family, other caregivers
-data must be pertinant, accurate
Id
evaluate
interpet
document
modify
Interperting & summarizing findings
eval. is easier to perform over an extended period of time
-each outcome & its priority should be evaluated
-failure to evaluate results in inadequate or inappropriate care decisions
id
evaluate
interpet
document
modify
Documentation is:

*
-a key element to all nursing care
-if you did not write it-you did not do it
-if you wrote it-you'd better have done it
-accurate info must be present in a clien'ts chart to facilitate ongoing eval. decisions
id
evaluate
interpet
document
modify
Modifying or Terminating Plans of Care:

*
Modification: when goals are not met-change in client's condition, error in nursing judgment or follow-up
-Termination- when expected outcomes are met-client has reached the goals and expected outcomes, communication of achievements to other health care personnel is crucial
id
evaluate
interpet
document
modify
Client Care Management
Nursing care delivery models

*
1.Functional nursing(task focused)
2.Team nursing (RN leads)
3. Total patient care (RN assumes responsibility for a caseload of clients over time)
4. Case Management-coordinates & links health care svcs. to clts and fam. while streamlining costs and maintaining quality
FTTC
Principles of Time Management
1. goal setting
2.time analysis
3.priority setting
4. interruption control
5. evaluation
What are the 5 rights of delegation?
right task
right circumstance
right person
right direction/communication
right supervision
Quality Management
Nursing practice:
must be defined
incorporate prof. standards & care guidelines
-specify outcomes
What is Self-Concept?
how one thinks and feels about oneself
What are the components of Self-Concept?
Identity
Body Image
Role Performance
Self-Esteem
How are role performance behaviors developed?
1.reinforcement-extinction
2.inhibition
3.substitution
4.imitation
5.identification
What are Self-concept stressors
1.Identity Stressors
2.Self-concept Stressors
3.Role performance stressors
4.Self-esteem stressors
What are Identity stressors?
-for adults, cultural and societal stressors are greater
-if adaptation doesn't occur, the person may experience disturbed personal identity
What are Body Image stressors?
changes in appearance
loss of function in body parts
significance of loss to the individual
What are role performance stressors?
-Conflict
=Ambiguity
-Strain
-Overload
What are Self-esteem stressors?
1. Chronic illness
2. Socioeconomic status
3. marital status
What are some effects on self-concept
family
nurse-non-judgmental
Implementaton for Self-esteem
health promotion-assist to dev. healthy lifestyle behaviors; measures that support coping and stress mgt
-Acute care: be aware of stressors and level of adaptation to changes in self concept
-Restorative care-mostly done in home health care situations-where a trusting relationship can led to steps to aleve the stressors in the home env. that are leading to the situational low self-esteem-doing self-evaluation, setting goals
Evaluation of self concept
client care
client expectations
goal attainment
What is Critical Thinking?
1.reasonable and reflective thinking that is focused on what to believe and do
2.Alexander & Giguere-is an intellectually disciplined process of conceptualizing, applying, analysing, synthesizing, and /or evaluating info
3.the nurse who is a good critical thinker faces problems without forming a quick, single solution
4. critical thinking is an active, organized, cognitive process used to carefully examine one's thinking and the thinking of others
Critical Thinking in Nursing
1. outcome is nursing judgment
2.all aspects are aggressively explored
3.all assumptions are open to question
Three levels in critical thinking
1.Basic
2.Complex
3.Commitment
Components of critical thinking in nursing
1.specific knowledge
2.clinical experience
3.critical thinking competencies
4.attitudes
5.standards
Attitudes for Critical thinking
1.self confidence
2.independent thinking
3.fairness
4.responsibility and accountability
5.risk taking
6.Discipline
7.perseverance
8.creativity
9.curiosity
10.integrity
11. intellectual humility
Standards for critical thinking
1.intellectual
2. professional
what are the 14 intellectual standards for critical thinking?
1.clear
2.precise
3.specific
4.accurate
5.relevent
6.plausible
7.consistent
8.logical
9.deep
10. broad
11.complete
12. significant
13. adequate
14. fair
What are the professional standards OF critical thinking?
1. ethical criteria for nursing judgments
2.scientific and practice-based criteria used for evaluation
3.criteria for professional responsibility
What are the professional standards FOR critical thinking?
1.sound ethical standards
2.scientifically based and practice-based criteria
3.professional organizations, practices, policies and procedures
What are three aspects of critical thinking?
1. reflection
2.language
3.intuition
Reflection in critical thinking is?
process of purposefully thinking back or recalling a situation to discover its purpose or meaning
Language in critical thinking is?
the ability to use language is closely associated with the ability to think meaningfully
Intuition in critical thinking is?
the direct understanding of particulars in a situation w/out conscious deliberation
Evidence of critical thinking in nursing
1. problem solving
2.scientific method
3.nursing process
4.diagnostic reasoning and inferences
5.intuition'
6.decision making
Critical thinking flow chart
1.identified need/problem
2.goal/outcomes
3.Knowledge/experience/Competencies required
4.questions that need to be answered
5.where to find the answers
6.answer or no answers/bad answers
7.action or further investigation
8. evaluation
synthesis: Critical thinking is:
1. reasoning process used by individuals to reflect on & analyze thoughts, actions, and knowledge
2. ongoing with information being analyzed from many sources
3. is synthesized with the nursing process to allow students to become competent professionals
Development of critical thinking skills
1.taught or developed
2. what kinds of activities can enhance critical thinking skills
3.indicators that critical thinking is developing
4.models of critical thinking
Nursing considerations for lab & diag. studies
1. reason for the lab or study
2.specific preps or post-care for the pt
3.specialized collection or equipment
What are some laboratory studies?
1. Chemistries
2.Hematology
3.Bacteriology or Microbiology
4. Blood bank
5. Pathology
What are some of the Hematology studies?
1.coagulation
2.blood cell counts, maturity
3.CBS,WBC,PT,PTT,INR, Iron levels, Folic acid, Vitamin B12 etc
What are some of the Bacteriology or Microbiology studies?
1. cultures on samples of blood & other body fluids
2.testing for sensitivity of organisms to antibiotics and other treatments
3. discovery of problem bacteria, fungi, ova and parasites through culturing
What are the studies done in a blood bank?
1. types and crossmatches of blood and other bl. products for compatibility
2.maintains storage
3. maintains and controls bl. product distribution
What are Pathology studies?
1.tissues are examined for cellular characteristics
2. tissue samples may be tested to substantiate a diagnosis, differentiate btw types of cells or after death to id. an abnormality
What labs tell us:
1. nurse must read and understand a pts lab results
2.should direct the nurse to give or hold meds, to monitor a pt or call the physician, to make a decision to act in one direction or another
Critical thinking and lab values
1.KNOWING the relevence of the number and steps to take or what to monitor
2.Understanding the diff. btw an abrupt drop or rise in a lab value versus a chronic condition
3. Are the values skewed by an underlying condition or problem (ex: right equip)
Critical thinking application and lab values
1.during med. admin-(use labs)
2.to establish need for isolation
3.to validate therapeutic responses
4.to formulate a diagnois
What are dianostic procedures?
Indirect visualizations (view on screen)
Direct visualizations(view w/a scope)
Critical thinking and diagnostic studies
1.holding certain meds prior to and/or after certain procedures
2.recognizing expected and untoward side effects of procedures
3.always ask clients about Otc and herbal preps.
Enviromental safety-individual risk factors
1.lifestyle
2.impaired mobility
3.sensory or communication impairment
4.lack of safety awareness
5.impaired vision
Client safety in the hospital
1.must be assessed by the nurse & corrected
2.risk for falls -use the fall assessment tool
3.risk for med. errors can be prevented-7 rights of med admin
What are the 7 rights of med administration?
right diagnosis
right med
right dose
right person
right route
right time
right documentation
Restraints- when client is at risk
since the nurse should do all that is possible to prevent falls then restraints may need to be used
only when pt is at risk from wandering or in a agitated or disruptive state
should be removed asap
-nurse should use extreme caution, frequent assessments and close monitoring
Alternatives to restraints
1.orient the client as often as necessary
2.encourage families to stay/or trained sitters
3.assign these pts to rooms close to nurses' station
4.use relaxation techniques
5.provide scheduled toileting to alleviate pts ambulation w/out assistance
Restraint application
1.delegated to trained assistive person
2.communicate w/pt about the reasons
3.physician's order is necessary
4.assess and docu. pts responses at least every two 2 hrs
5.tie w/quick release knots
-assess pulse and skin every 2 hrs or more
6.notate the use in chart & during report
Institutional environmental risk are:
1.falls
2.client-inherent accidents
3.procedure-related accidents
4.equip. related accidents
Some nursing diagnoses pertaining to safety
1.impaired memory/disturbed thought processes
2.risk for poisoning
3.disturbed sleep pattern
4.impaired physical mobility
5.risk for injury
6.disturbed sensory perception
7.acute/chronic pain
Theory is?
the domain and paradigm of nursing
Domain is?
a.view or perspective of the discipline
b.contains the subject,central concepts, values, & beliefs, phenomena of interest & central problems of the discipline
Paradigm is?
model that explains the linkage of science, philosophy & theory accepted and applied by the discipline
Nursing Paradigm is?
directs the activity of the nursing profession
What are the 4 linkages of the Nursing paradigm?
1. person
2.health
3.environment/situation
4.nursing
theory
set of concepts, definitions, relationships and assumptions that project a systematic view of phenomena
Nursing theory
a conceptualization of some aspect of nursing communicated for the purpose of describing, explaining, predicting and /or prescribing nursing care
Components of a theory
1. concepts
2.definitions
3.assumptions
4.phenomenon
Concepts of a theory?
come from individual perceptual experience
-help to describe or label phenomena
Definitions of a theory
convey the general meaning so it fits the theory
describes the activity necessary to measure (test) the constricts, relationships or variables within that theory
Assumptions of a theory
-statements that describe concepts or connect two concepts that are factual
-taken for granted statements that determine the nature of the concepts, definitions, purpose, relationships and structure of the theory
Phenomenon of a theory
a.an aspect of reality that can be consciously sensed or experienced
b.nursing theories focus on the phenomena of nursing and nursing care
c.reflect the domain of nursing practice
Types of Theories
1. Grand
2.Middle range
middle range theories are:
1.limited scope, less abstract, address specific phenomena or concepts, reflect practice
2. Descriptive theories-
a.1st level of theory development
b. describe phenomena, speculate on why phenomena occur, describe consequences of phenomena
3. Prescriptive theories: address nursing interventions and predict the consequence of a specific nursing intervention
Theoretical models
refers to global ideas about the individuals, groups, situations, or events of interest to a specific discipline from the view of the theorist
Interdisciplinary theories
1.Systems theory
2.Basic Human needs
3. Health-and-Wellness models
4.Stress & adaptation
5.Developmental theories
6. Psychosocial theories
Systems theory is
a. input enters from the system
b. output is the end product of the system
c.feedback is the process that returns output into the system
d. systems may be open or closed
e. nursing process-open system b/c influenced by environment
f. chemical reaction-gets result
Basic Human Needs theory is
a. useful for designating priorties of care
b. Maslow's Hierarchy of Needs
c. levels id basic to complex needs to be met
Health and Wellness models
designed to help health care professionals understand relationships btw the two concepts and clients attitudes toward health
Stress & adaptation
a. universal and dynamic
b. physiological and behavioral
Developmental theories
a. orderly, predictive process beginning with conception and continuing through until death
b. many models available that describe and predict behavioral and development at phases of the life continum
Psychosocial theories
a. physiological, psychological, sociocultural, developmental and spiritual
b. theories predict client responses to each of these domains
Scientific research and evidence-based practice in nursing
Knowledge acquisition-hallmark of a mature discipline is development of multiple research methods designed to develop a knowledge base unique to the discipline
Methods of knowledge acquisition
a. tradition
b. information seeking
c. experience
d. problem solving
e. critical thinking
The Scientific Method is:
a. foundation of research
b. most reliable and objective
c. used to understand, explain, predict or control
d. produces empirical data (based on experience rather than scientific)
Nursing research:
a. addresses issues that are important to the discipline of nursing
b. can focus on clinical nursing, nursing ed. client care, health care delivery or a comb.
c. can use different methods to ascertain the information
Methodologies of Nursing research
a.Quantitative:experimental, surveys, evaluation
b.Qualitative: interviews, several design structures
c. mixed methods: combination of both
Ethical Issues in Nursing research
a.rights of human subjects
b.informed consent
c. anonymity
d.confidentiality
e. HIPPA
f.IRB
HIPPA
makes regulations to keep pt info confidential
IRB
Institutional Review Board-research board looking for problems
Nursing Practice based on Research
1. Research report-more expensive
2. Clinical article
Research report includes
reported by primary or secondary source
a. abstract
b.introduction
3.methods
4.results
5. discussion
6.reference list
Nursing research utilization
a. improves the practice of nursing
b.raises the standards for the profession
c. promotion & use increase the scientific knowledge base for nursing practice
d. recipients of improvement are the consumers of nursing care
Nursing Health History
building road map to pt
a. objective is to id patterns of health and illness, risk factors for physical and behavorial health problems, deviations from normal and help find solutions
Guidelines for Conducting a Health Assessment
1. establish rapport
2.encourage honest communication
3.make eye contact
4.listen carefully
5.be aware of your own nonverbal communication
6.avoid technical terms-communicate in a way that is easily understood
7. consider educational & cultural background and any disabilities that the pt may have
Components of the Health History are:
1. Biographical data-name, age, sex, race, marital status, ss.#, ed. occupation, religion, closest relative, physician, and med. record number
Components of the Health History are:
2,Chief Complaint- in the pts own words and in quotation marks
Components of the Health History are:
3. Present Health Concern-history of the present illness is the single most important factor
a.physical exam validates the info obtained
b.diagnostic test often support rather than establish diagnosis
c. gather relevant & essential data about the onset and duration of symptions
d.record info. about the location, intensity, and quality of symptoms
e.find out what action precipitates the symptom, makes them worse or provides relief
Components of the Health History are:
4.Past History
a.prior hospitalization
b.allergies
c.if allergy note reactions and treatment
d.id habits and lifestyles
e.alcohol, tobacco, caffeine, OATC or routinely taken meds. *Noting the habit provides essential data
f.assess patterns of sleep, exercise and nutrition
g.general health status, immunization status
h. last physical exam, CXR, EKG, eye exam, dental checkup, pap smear, mammogram, testicular and digital rectal exam
i. previous illnesses are discussed
Components of the Health History are:
5.Family History-
a.age, health status, or the age and cause of death of relatives
b.1st order relatives (parents,siblings, spouse, children)
c.second order relatives (grandparents, cousins)
d.diseases:
e. genogram or family tree is an easy way to record such data
Components of the Health History are:
6.Environmental History
a.info about client's home env. and support systems
b.includes function of utilities, layout of rooms, presence of barriers or risks to client safety
c.ids exposure to pollutants, high crime areas and available resources
Components of the Health History are:
6.Psychosocial History
a. reveals suport systems
b.reveals info about how client deals w/stress
c.reveals if pt has had recent losses that create a sense of grief
Components of the Health History are:
7. Spiritual Environment
a.shaped by one's spirituality
b.spiritual dimension is diff. to assess quickly
c.review the client's belief about life, their source of guidance in acting on beliefs and the relationship they have w/ others in exercising their faith
Components of the Health History are:
8.Review of Systems-
a.systematic method for collecting data on all body systems
b.info provides a systematic description of the 11 functional health patterns and the pt perception, evaluation and explanation of particular problems
c. info used to establish the database criteria against which any future changes are evaluated
d.includes an overview of general health as well as symptoms related to ea body system
e. it is not necessary to repeat previously obtained info
Components of the Health History are:
9. Patient Profile
a.info is highly subjective and personal
b.pt is encouraged to express feelings honestly
c.begin w/general, open-ended quetions and move to direct specific questions
d.past life events related to health
e.education & occupation
f.environment
g.lifestyle
h.presence of a physical or mental disability
j.self-concept
l.sexuality
m. risk for abuse
n.stress and coping response
Components of the Health History are:
10. Cultural Considerations
a. care provider must take into account that other cultures have their own folklore and beliefs about the treatment of illnesses
b.always respect other persons' beliefs, even if they conflict with yours
Components of the Health History are:
11.Ethical/Legal use of history or physical exam data
a.pt has a right to know why the info is being sought and how it will be used
b.important that they are aware that the decision to participate is voluntary
c.written data should be stored in the pt's chart and made available only to those health professionals directly involved in the care of the pt
Components of the Health History are:
12. Physical Examination
a.performed after the health history
b.pt is asked to undress and drape apprp so that only the area to be examined is exposed
c.procedures and sensations to expect are described to the pt b4 each part of the exam
d.WASH hands, gloves
e.an organized and systematic approach is key
ophthalmoscope
Otoscope
Tuning fork
Percussion hammer
Physical Assessment Techniques
1.Inspection
2.Palpation
3.Percussion
4.Auscultation
Physical Assessment Techniques: Inspection
1.deliberate, purposeful observations performed in a systematic manner
2.informed observation
3.visual, auditory & olfactory senses
4.adequate lighting
5.inspect ea area of body for size, color, shape, position & symmetry
6.look for rashes, scars, surgical scars, insect bites, sores, skin breakdown ets
7. a comparison of bilateral body parts is necessary for recognizing abnormal findings
Physical Assessment Techniques: Palpation
1.uses sense of touch
2.used to gather info
3.dorsum of hand & fingers(used for gross measure of temp)
4.fingertips (nerve endings)(pulses, lymph nodes, & breasts)
5.palm of hand (vibs can be felt better with palm of hand)(especially the metacarpal joints-thrills)
6.what if you felt: warm and dry skin? hot skin? cold & clammy skin?
7. get into the habit when taking the BP to ask yourself-"what is the temperature of the skin?"
8. General guidelines for Palpation
Palpation
gathers info about:
temp,turgor,texture, quality of pulses, edema, extent of tenderness, moisture,chest wall vibs, shunt thrills, abdomen softness or rigidity
General Guidelines for Palpation
1.warm, comfortable,relaxed env
2.nurse's hands warm & fingernails short
3.any area of tenderness is palpated last
4.any expression of distress or pain should prompt the nurse to palpate lightly
5."Tickles" -use pt's hand to start palpation with
6.light & deep palpation
7.controlled by the amt of pressure applied
8.exert & release fingertips several times over an area
9. place hand parallel to the body surface that is to be palpated
10. move in a circular motion
11.light--1/2"
12. deep--about 1"
Deep Palpation
***risk of possible internal injury***
1. do with caution
2.done after light pal.
3.used to detect abdominal masses
4.fingers are held at a greater angle to the body surface than light palpation
Percussion
assesses the location, shape, size & density of tissue
Four characteristics of sound
intensity
pitch
duration
quality
Five percussion tones
tympany
resonance
hyperresonance
dullness
flatness
Percussion: Indirect method
-place stationary finger over specific area
-keep palm & other fingers off the surface
-apply light, uniform pressure
-other hand--cock hand at wrist
-use tip of striking finger
-deliver blow btw knuckle & base of nail
Auscultation
listening w/stethoscope
-used to listen over the lungs, heart, blood vessels, & abdominal viscera
Stethoscope
a. diaphragm (firmly placed) to detect high-pitched sounds, such as normal heart tones & bowel sounds (S1,S2, friction rub, lung sounds, & abdominal sounds)
2. Bell (lightly placed) to detect low-pitched sounds, such as those produced by the heart & vascular system (S3, S4 & certain murmurs)
Bedside Head to Toe assessment
1. general survey--general overview
2. what do you observe-inspection-informed observation
3.any immediate needs?
a.observe for pain, dyspnea, anxiety
b.general appearance-posture, skin color, facial expression, comfortable
Holistic care
a.thorough data gathering, assess for anxiety, fear, affect and/or other emotional distresses
b. brief Neurological Exam:
1.orientation
2.response to verbal command
3.pupils
4.muscle strength
Starting an Assessment:
I.orientation
II.response to Verbal command
III. Consciousness
IV. Level of consciousness
V. Skin
VI. hair & scalp
VII. pupils
VIII. nose & sinuses
IX. Oral Mucous Membranes
X. Vital signs
XI. Chest
XII. Heart
XIII. Abdomen
XIV Peripheral Vascular Assessment
XV. Evaluate all
XVI. Documentation
Assessment: Orientation
1.direct questions-responses
2.assess for Oriented X 3
3.note speech content & patterns
4.doc. exact response-not "appears confused"
Assessment: Response to Verbal Commands
1.does pt respond to verbal stimuli?
2.if no response to verbal commande, try: shout--sternal rub---pain
Assessment: Level of Consciousness
1.Glasgow Coma Scale
2.level of consciousness
a.awake and alert
b.Lethargic
c.Stuporous
d.Comatose
Assessment: Skin
1.color
2.temp
3.moisture
4.Nail color, capillary refill
5.Turgor
6.Edema
7. Texture
8. Any scars, rashes, insect bites
9. Redness or breakdown
Assessment: Skin con't
a. check for edema-blanching, pitting
b. Petechiae-may indicate blood-clotting disorders, liver disease, or drug reactions
Edema Scale
0=none
+1-2mm=trace
+2-4mm=moderate
+3-6mm=deep
+4-8mm=very deep
Assessment: type of skin lesions
1.macule-fairly flat
2.papule-slightly raised, maybe inflammed
3.nodule-firm
4.-tumor-mass of cells benign or malignant
5.-wheal-raised, redened area
6.vesicle-fluid filled-clustered
7.pustule-pus filled
8. ulcer-missing tissue-1st or 2nd layer
9. atrophy-arterial insufficiency, holes deeper, smells bad, gangrene could form
Assessment: skin color
cyanosis
1.central cyanosis: around lips & mouth-low arterial saturation
2.peripheral cyanosis: fingers, toes, & tip of nose--assoc. w/venous saturation
Assessment: hair & scalp
1.itchy scalp, alopecia, excessive body hair
2.does the client wear a wig?
3. are there open sores, etc?
Assessment: pupils
1.inspect size, shape, equality of pupils
2.partially darken room
3.instruct pt to stare straight ahead
4.test reaction of pupils to light (constriction & rate) sluggish brisk
5.approach penlight from side
6. PERRLA
Assessment: pupils-PERRLA
pupils equal, round, reactive to light, accomadate
Assessment: Glasgow Coma Scale
1.three perameters
a. eye opening -1-4
b. motor response-1-6
c. verbal response 1-5
Assessment: Nose & sinuses
1. observe shape, size, skin, color & presence of deformity or inflammation
2.note any tenderness, masses or underlying deviations
3.assess patency of nares
4.inspect mucosa for color, lesions, discharge, swelling, and evidence of bleeding (use penlight)
Assessment: Oral Mucous Membranes
1.normally pink, intact, & moist
2.should be free of swelling, lesion, cyanosis, bleeding gums
3.assess teeth for caries
Assessment: Vital Signs
1. always part of head-to-toe
2.temperature
3.if nursing assistant takes temp, make sure you know what the reading is
a. if pt feels hot or looks flushed-check the temp, even if not time to check the temp
4. Respirations
5. Blood pressure-may need to take in both arms
6. other concers
a. after taking vital signs, ask yourself- Is this normal?
b. if normal, chart the signs
c. if abnormal, report the vital signs
Assessment: vital signs- respirations
a. rate, depth, rhythm, character
b. normal rate-12-20 min
c. symmetry of chest wall movement(may need history)
d.any accessory muscles in use
e. O2 in use
f. cough, sputum character
Assessment: Chest- techniques used
1. chest inspection
2. chest palpation
3.vocal fremitus
4.chest percussion
5.chest auscultation
6.4 types of sounds aucultated over lungs
7.normal breath sounds
8.abnormal breath sounds
Assessment: chest- techniques used: Inspection
a. assess color, shape or contour, breathing patterns & muscle development
b. normally transverse diameter is greater than the anterior-posterior diameter
Assessment: chest- techniques used: Palpation
a. used to detect areas of sensitivity, chest expansion during respirations & vibrations (fremitus)
c. palmer surface of hands used
Assessment: chest- techniques used: Vocal Fremitus
a. vibs transmitted to the chest wall during speech
b.place ball of hand lightly on chest--instruct the patient to say "ninety-nine"
c.dense tissue conducts sound better than air; therefore, pneumonia will increase intensity of vibs
d. fremitus decreased in pneumothorax, asthma, empysema--due to trapped air
e.normal: mild vib sensations; equal bilaterally
Assessment: chest- techniques used: Chest percussion
a. used to determine lung position & size, to detect presence of air, liquids, or solids w/in the lungs
b. resonance-normal percussion tone for the lungs
c.flat--over bony & well-developed muscle tissue
d.Tympany--over the stomach
e. Hyperresnance--over the emphysematous lung tissue (return of sound is absent)
f. dullness-over fluid or a solid mass
Assessment: chest- techniques used: Chest Auscultation
a. used to detect air flow w/in the respiratory tract
b.breath sounds normally clear
c.vesicular over peripheral lung fields
Assessment: chest- techniques used: four types of sounds ausculated over lungs
a. lung sounds
b. adventitous sounds
c. voice sounds
d. whispered sounds
Assessment: chest- techniques used: Normal Breath sounds
a. vesicular
b. bronchovesicular
c. Bronchial
Assessment: chest- techniques used: Abnormal breath sounds
a. crackles (rales)
b. fine
c. coarse
d. wheezes
e. rhonchi
f. pleural friction rub
Assessment: Heart assessment-techniques used
a. inspection
b. palpation
c. auscultation
Assessment: heart inspection
a. check for neck vein distention (NVD) @ 30-45 degree angle
b. check the precordium for visible pulsations
c. generally no visible pulsation, except @ the PMI
Assessment: Heart palpation
a. precordium palpated for the presence of pulsations
b. systematic manner--cardiac landmarks--aorta, pulmonic, tricuspid, & mitral areas
c. gently palpate w/4 fingers held together
d. normal findings:
1. no pulsation over the aortic & pulmonic areas, w/pulsation at the PMI
e. abnormal findings
1. thrills
2. fine,palable, rushing vibs over the right or left 2nd intercostal space
3.lifts or heaves
4. a rise along the border of the sternum with ea heartbeat
Assessment: Heart Ausculation
a. closure of the four heart valves
b. listen systemically
c. client should breathe normally
d. listen first w/ diaphragm, listen to apical pulse for 1 full min
e. then, listen w/the bell (for low pitch sounds-where problems are)
f. focus on overall rate & rhythm of the heart & the normal sounds (S1 & S2)
Assessment: Abnormal Heart sounds
a. S3
b. S4
c. murmurs
d. bruits
e. pericardial friction rub
apex of heart is where you will hear tri-cuspid valve
Assessment: Abdomen- techniques used
a. inspection
b. ausculation
c. percussion
d. palpation
e. nine regions
f. assessment
Assessment: Abdomenal inspection
a. inspect for shape, color, symmetry, pulsatons, masses
b.should be evenly rounded or symmetric, w/out visible peristalsis
c. in thin people--an upper pulsation may normally be visible (epigastric region)
Assessment: Abdominal Ausculation
a. used to assess bowel sounds & vascular sounds
b. systemic manner
Assessment: Abdominal Auscultation
*used to assess bowel sounds & vascular sounds-4 quad.
2.systematic manner
a. warm stethoscope
b.note frequency & character of bowel sounds
c. clicks and gurgles
d. usually every 5-20 sec
e. listen for 5 full min, b4 deciding bowel sounds are absent
Assessment: Abdominal Percussion
a. used to identiy fluid, masses or air'
1. tympany-over air filled organgs
2.dullness-over liver, tumor, fluid
3. dullness--ovr full bladder
4. normally--predominatley tympany
Assessment: Abdominal Palpation
a. pads of fingers are used to palpatate w.\/ a light, gentle, dipping motion
b. watch face for nonverbal signs of pain during palpation
c.systematic manner
1. normal--soft, relaxed & free of tenderness
Assessment: Nine Regions
a. right hypochondriac
b. left hypochondriac
c. right lumbar
d. left lumbar
e. right inguinal
f. left inguinal
g. epigastric
h. umbilical
i hypogastric
Assessment: abdominal assessment questions
a. good time to talk about last BM?
b. Any problems with urination?
c. abnormal abdominal finding
1. distension
2.absent, hypoactive, or hyperactive bowel sounds
3. increased or decreased tympany/increased dullness
4. rigidity
5. spasm, pain
Assessment: Peripheral Vascular Assessment- techniques used
a. inspect for color, edema, rashes, ulcers (esp on heels)
b. compare size of legs and feet
Assessment: Peripheral palpation
a. used to assess temp, pulses, edema, capillary refill
b. use pads of the index & middle fingers to palpate for strength & quality
Assessment: Radial Pulse
a. rate, rhythm, volume
b. compare radial pulses bilaterally
c. normal rate--60-100 beats per min
if have problem with this use apical pulse
Pulse scale
0=absent
+1=thready, weak
+2=normal
+3=increased
+4=bounding
Assessment: Muscle strength
1. test bilateral hand grips
2. MAE equally?
3. Active ROM of all extreemities?
4. Any numbness or tingling?
5. test muscle strength & ability to follow commands
6. Homan's sign- pain in the calf- may be deep vein thrombosis
7. dorsiflex the foot & note pain in calf, if positive then report it
8. assess both legs
Assessment: Evaluate all
1. IV lines
2. tubes
3. dressings
4. incisions
5 equipment
6. nursing process