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35 Cards in this Set

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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
information documented is:
descriptive
concise
no interpretations
Nurse records:
contain what?
observations

statements made by others
why do we need data?
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
nursing process: the assessment
3 methods here:

observation, interview, and ...
physical assessment
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
by looking at the patient, we can learn by looking at what?
skin
grooming
nourishment
body language
LOC (level of conscious)
O2 status
abnormalities
concerning the physical assessment, what?
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!
what is the challange to all this?
to recognize changes and address them
what are 4 techniques to assess?
inspection by looking
palpation using hands/touch
percussion/tapping
Auscultations: listening
So we need a good light, have to expose their body parts, look for symentry, and ...
use all our senses:
look
listen
touch
smell
HOW DO YOU START A P/A ?
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
How do you prepare the patient for a P A ?
make sure its warm enough
private setting
enough light
patient is comfortable
its quiet
temperature
proper clothes
lighting
quiet
prevent interuptions
how about the patient and doing a P A ?
prepare them physically and psycologically
tense, anxious, may not co operate
provide for modesty
convey approach
be open
be receptive
be professional
look around the room, whats going on?
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!
Vital signs:
part of the P A
what does this do?
gives nurse chance to touch skin
can the patient follow commands?
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.
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
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
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
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
stethoscope:
abnormal heart sounds use the bell for low sounds
normal heart and lung sounds are ...
high pitched
use the diaphram, the large part
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
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
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)
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
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
Listen to abdomen
start where?
right lower quad
air moving thru
tinkling sound
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
Palpation

do what?
follow listening path as before
use small circular motions
should be soft, no hard spots, or lumps
what situations whould you never pappate?
*************************
abdominal aortic aneurism
appendicitis
kidney transplant
polycystic kidney disease
tender spleen
known abdominal tumor
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
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
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
CMS what is this?
Color
Motion
Sensation

check it if they have a cast on!
range of motion
independant
SBA
limitations
precautions
assistive measures
note any deficits like...
vision or hearing