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35 Cards in this Set
- Front
- Back
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the nursing observation.
what is the purpose of the assessment? |
to establish a data base
includes: level of wellness ??????????? 4 other things |
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information documented is:
descriptive concise no interpretations Nurse records: contain what? |
observations
statements made by others |
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why do we need data?
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to ID problems
is a basis for individualized care plan must be accurate so plan is appropiate errors in data equal errors in care plan |
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nursing process: the assessment
3 methods here: observation, interview, and ... |
physical assessment
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concerning the observation, we must be:
looking being observant what can we learn? |
gender
O2 levels age any pain hydration status possible fever body language indicates emotional status nutritional status perspiration, breathing rate, coughing, sneezing if their upset like crying any deformitites bruising |
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by looking at the patient, we can learn by looking at what?
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skin
grooming nourishment body language LOC (level of conscious) O2 status abnormalities |
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concerning the physical assessment, what?
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do it many times a shift
b/c automatic do it in a systematic fashion head to toe ducumented by systems do it in same order each time We MAY have to integrate a PA with regular nursing care! |
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what is the challange to all this?
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to recognize changes and address them
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what are 4 techniques to assess?
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inspection by looking
palpation using hands/touch percussion/tapping Auscultations: listening |
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So we need a good light, have to expose their body parts, look for symentry, and ...
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use all our senses:
look listen touch smell |
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HOW DO YOU START A P/A ?
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enter room
wash hands introduce ID patient provide privacy shut door/pull curtain EXPLAIN!!! tell them what your going to do! allow them to go to the bathroom first |
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How do you prepare the patient for a P A ?
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make sure its warm enough
private setting enough light patient is comfortable its quiet temperature proper clothes lighting quiet prevent interuptions |
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how about the patient and doing a P A ?
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prepare them physically and psycologically
tense, anxious, may not co operate provide for modesty convey approach be open be receptive be professional |
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look around the room, whats going on?
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is there an IV going? tubing, ck the site
O2. flow rate, tubing, mask/prongs NG tube: to suction, drainage apperance? SCDs: sequential compression device CPM continual passive motion foley cathetur: color, amt. any gear in there. ask about it! |
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Vital signs:
part of the P A what does this do? |
gives nurse chance to touch skin
can the patient follow commands? |
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you do this PA head to toe!
start how? |
Orientation/LOC
place...where are you? location, city, state person do you know who's in the room and their roles? whos's your doctor? time do they know time, day, week, month, season, make year last of this. |
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LOC
are they lethargic? sleeping but arouses to voice responds to stimuli can be alerted but confused |
if OK, document as A & O X 3
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EYES are next!
PERRLA means ... |
Pupils Equal Round Reactive to Light Accommodation
are pupils equal are pupils round are pupils reactive to light Accommodation can focus from distance to up close pupils should converge and constrict |
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SKIN next:
color dry or moist temperature should be ... |
warm!
look for: swelling rashes buises redness terger on chest or forehead chart either stat or tenting as a delayed return |
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CHEST!
Lungs: start at the top of the lung above the clavical never listen thru a gown! listen ...! |
posteriorly and anteriorly
sit at edge of bed have patient say if they are getting dizzy or feel nausea look for normal oval or barrell chest! listen for RATE & EXERTION shivering chest hair talking clothes tube of stethescope hitting stuff |
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stethoscope:
abnormal heart sounds use the bell for low sounds normal heart and lung sounds are ... |
high pitched
use the diaphram, the large part |
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HEART:
normal heart sounds S1 and S2 where do you hear S1? |
S1 closure of the AV valves
mitral & tricuspid heart is in systole best heard at apex or 4 intercostal spance just left of the sternum |
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some respiratory terms:
paroxymal nocternal dyspena (PND) Orthopena have them sit up to breath Barrel chest. what about land marks? |
mid clavicular line (MCL)
costal margins costal vertebral angle (where kidneys are) mid axillary line |
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BREATH SOUNDS
what do they sound like? traceal sounds? Bronchovesicular sounds? Vescular sounds: Adventitius sounds ( abnormal lung sounds) what are abnormal sounds? |
wheezes
crackles (fine or coarse) pleural rub stridor (horse croup sound) Caused by: air going thru moisture air going thru mucus air going thru narrowed airways inflammed lining(plura rubbing) |
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ABDOMEN
make sure they pee first lay flat as possible ask about any pain anywhere tell them to tell you if they experience pain during this look for boney landmarks like? |
zyphrod process
costal margins iliac crest pubic bone |
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then concerning the abdomen, the quaderants there are 4
ask when last bowel movement was. look first! look for what? |
skin abnormalities
shape wounds bruising |
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Listen to abdomen
start where? |
right lower quad
air moving thru tinkling sound |
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then move to right upper quad
then left upper, then left lower. must listen for at least ... |
5 minutes b/f you can say there are no bowel sounds!
(make sure steth is warm) make sure patient is relaxed |
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Palpation
do what? |
follow listening path as before
use small circular motions should be soft, no hard spots, or lumps |
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what situations whould you never pappate?
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abdominal aortic aneurism
appendicitis kidney transplant polycystic kidney disease tender spleen known abdominal tumor |
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Vascular:
orthostatic blood pressure know what it is & how to do it ck for CRT. what is that? |
capillary refill time. 3 seconds or less
do it in fingers and toes ck each hand and foot too! chart as CRT X4<3seconds |
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FEET
ck petal pulse look for what? |
symmentry
equal Homans sign (tells if there is a blood clot) doral flex foot and ask about any pain in calf |
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other pulses to know:
carotid in the neck do this gently b/c you could break of a chunk of plaque and kill them radial pulse is in the wrist femoral is in groin area popiteal is where? |
behind knee
petal pulse is top of foot post tibial is b/t anke & heel |
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CMS what is this?
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Color
Motion Sensation check it if they have a cast on! |
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range of motion
independant SBA limitations precautions assistive measures note any deficits like... |
vision or hearing
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