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94 Cards in this Set
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how do you check the orientation? hint: these should be questions concerning PERSON meaining
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this is the orientatuion X 3 part of the evaluation.
allways preffice with "I know these are going to be silly questions but its part of the assessement. Is it ok to ask do you know where you are? what state you are in? Do you know who I am or who this person sitting with you is? do you know who your doctor is? |
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so this again is orientation of person which is the assessment of the patients...
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can they tell us their name and the names of those in the room and what their roles are. who is this person with you? (daughter/brother) what their roles are. dddddddddddd
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there is then to ask
what time, season, month, ask last what year it is. they miss the year they are.. |
not completely oriented to time if they miss the year. this is an assessment of one's location in the continum of time and space and of one'e identity of one's self and flamiliar others. that again is time, place, and person.
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how do we chart orientation, they do good on all three? orientation times 3. what about level of consciouceness? a decreased level of consciousness?
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responds to verbal stimuli
unresponsive responds to blah blah alert and confused you can be oriented, alert but confused. oriented times 2 and explain what they are not oriented to. again, person, place, and time. |
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person you name
place hospital rm # city state, time ... |
day, week, season, year
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this is head to toe assessment, and we've just discussed is LOC (level of consciousness and orientation.
**************************** so, we did LOC, orientatin, whats next? |
the eye.
we want to check for PERRLA. this stands for: pupils are equal round reactive to light, and accomodation. ***************************** |
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what are some things that would change a pupils shape? an injury, a head injury. Whats important about the pupils?
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that the pupils are equal, round, and reactive to light. and accomodation. this is all about the optic nerve and brain function.
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to check the pupils we need to change the enviorment. if the patient is faced toward the window, what do we do?
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dim the room, close the window so you can get a reaction in their eyes b/c their pupils would already be constricted.
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so we look at the pupils to see that they are equal and round, then what?
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if they react to light. we want to assess 2 things in regards to light.
Direct and Concentual. **************************** Direct means you shine you light into the pupil and that pupil constricts. Concentual means you shine the light into the samee pupil and the OTHER pupil constricts also. ************************** concentual means the eyes both react at the same time although the light is in one eye only. |
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so dim the light, put your hand up to block the light from the other eye, what do you not have to do?
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shine it directly in the eye. then do the same to the other eye. you check for direct and concentual in both eyes.
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how do you check for accomodation of the eye?
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focusing on a distance then to a close distance. find the farthest corner and allow them to focus for 10-15 secs and then tell them to focus on your finger about 4 inches. the pupils should converge and constrict. this is accoumodation. if eyes didn't do this, a problem with the optic nerve and damage to their vision center from a head injury.
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SKIN. color. what color should it be? depends on their race. also if its dry or moist. and its temperature. how can you tell its temp?
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by touch. so we have so far did their LOC, their orientation, their eyes, now their skin. we should of already assess the skin from doing their vital signs and already know their color, moist or dry, and temperature.
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is healthy skin moist or dry. it should be dry. what were talking about is...
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that its not wet. the skin shouldn't be wet. we also look for tackness. swelling, edema, or any other abnormalities like bruises, rashes, etc.
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there are 2 places to check turgor, the chest and forehead. what are checking for?
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tenting. it tests for hydration. it should immediateley return. if it stays in a tent, they are dehydrated.
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when we document turgor we don't say its normal. you would say turgor with ...
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stat return or delayed return or tented. but don't say anything is within normal limits.
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remember stat return. delayed return or tenting.
Now the chest. 2 things we assess in the chest. what are they? |
lungs and heart.
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Lungs we will talk about one lung has 2 lobes, the right has 3 the left has 2. were are the very tips of the lungs be?
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above the clavicles
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never listen to lung sounds ...
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thru the gown. NEVER try to listen thru the gown.
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so ask the patient to sit on the edge of the bed, listen to the anterior lung sounds, then what?
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the heart, then go to the back and do the posterior lungs sounds.
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what do we ask the patient before they start taking deep breathes?
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please let me know if this makes you dizzy.
**************************** this procedure is like hyperventilating. pay attention to them while listening to lung sounds! |
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we will be looking at the chest. the shape of the chest. what is a normal shape of the chest be?
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oval is a normal shape. about twice as wide as thick. COPD (chronic something pulmonary disease) causes a barrel chest.
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while doing this, look to see if their spine is straight, pay attentin to also to ...
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respiratory rate,
we are assessing resiptory status here. |
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what other sounds would we here doing this?
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bumping sounds, patient talking, so be carefull. chest hair or if they are shivering. so place the stethscope where there is no hair.
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abnormal heart sounds are low pitched. lung sounds, bowel sounds and normal heart sounds are high pitched. what part of the stetescope do we listen to abnormal heart sounds?
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the bell to hear low pitched sounds. high pitched sounds are heard with a diaphram stethescope. the bell is for heart sounds but for abnormal heart sounds. a bell would hear a heart murmer.
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finding the apical heart rate landmarks. how do you find this landmark?
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go to the manubrium
then go down to the angle of Louie go out 2 inches and thats the intercostal space count down to the 5 intercostal space then go over to the midclavicular line and that should be the apex of the heart. |
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heart sounds. what are the two normal heart sounds.
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S1 and S2 are the two normal heart sounds. the sounds we here are valve closures. The AV valves. the tricuspid and mitral valves. called AV b/c they are located b/t the atrium and ventricles so they call them the AV valves.
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again, what are the 2 valves b/t the artiums and ventricles of the heart?
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mitral valve (on the left)
tricuspid valve(on the right) Mitral means bicuspid by the way. |
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what is the heart doing when the valves are closed? they are contracting which sends blood out. S1 is systolie, when ...
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the AV valves close
************************** S1 is best heard either at the apex of the heart OR 4th intercostal space just left of the sternum. that would be the tricuspid valve. |
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so the 2 places to hear S1 is the 5th intercostal space, mid clavicular line, or ...
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the 4th intercostal space just left of the sternum.
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S1 is the lub sound. the lub in these 2 place would sound LUB dub LUB dub. what is the sound of S2 sound?
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the closure of semilumar valves, which are the pulmonary and aortic valve closures.
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so the S2 sound has the DUB emphasised. you will hear lub DUB, lub DUB. where can you hear the S2 sound?
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second intercostal space, either side, about 2 inches from the sternum.
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so far we have talked about head to toe, LOC, Perrla, skin, heart, now we learn the ...
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abdomen. this is the part where we ask the patient to empty their bladder. You cannot assess in a chair, they must be flat as possible.
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what would be a problem with someone being flat as possible with an abdomen assessment?
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if they have breathing problems and being in that position is difficult for them. so can't be flat too long.
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we have landmarks to describe the abdoment. like the ...
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Xiford process
the costal margins, the iliac crest the pubic bone |
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the other way we do is describe the abdomen in quadrents. like where a scar is. where do we draw the lines to divide up these quadrants?
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a line from the Xiford process down to the pubic bone. then draw across from the iliac crest. so, we have right lower quadrent, the right upper quadrent, the left upper quatrent, the left lower quatrent.
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what are we intrested in knowing about the abdomen?
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any enlargements. what do we need to know form the patient?
you ask "are you having any pain in your abdomen?" when did you have your last bowel movement and is that normal for you? |
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what are looking for around the abdomen? look at their abdomen, look for bruising, skin abnormalities, the shape, is it, distended but we are not...
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touching it yet! look at the skin, shape, symmentry. Then listen and not papate and start in the lower right quadrent. where the ileum cecum bowel area is tnd is the best place to here bowel sounds too. !!!!!!!!!!!
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its important to do abdominal assessment is a specific order! why?
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it can change the abdomonial sounds.
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what is it we here when we hear bowel sounds? its not peristalis. its ...
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the movement of air and fluid thru the small bowel.
******************** it should be high pitched and tinkling from 5 to 30 a minute. |
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why do we listen to the bowel b/f we palpate?
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you can stop or change bowel sounds just be touching someone!!!
*********************** so right lower, right upper, left upper, then left lower. |
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before you say there are no bowel sounds, you need to listen how much?
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listen for 5 minutes b/f you say there are absolutely no bowel sounds.
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why are we concerned with bowel sounds anyway?
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anybody who has had bowel surgery, any time the bowel has been handled or touched by a surgeon, it stops working! so we need to know when that bowel starts working again.
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be sure the stethescope is warm and the patient is relaxed. what happens when they lift their head?
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it tightens the abdomen so tell them to relax. Ask if there is any pain in the area? we also must say, "let me know if anything i do causes you any pain."
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after listening we palpate with our hands on the soft areas of the abdomen. we shouldn't feel any ...
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lumps or bumps
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there are some abdominal things in which we would never palpate the abdomen. what? |
a diagnosised aortic arthymn
a suspected appendixitices a kidney transplant if they have polycystic kidney disease a tender slpeen a known abdominal tumor BECAUSE of doing any harm. |
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so we look, listen, and then ...
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feel. And we would document in this order too. say, the abdomen is flat, has active bowel sounds, and is non tender to light palpations. Next year we will do deep palpations.
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while the patient is lying flat, what would this be a great time to do?
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palpate the femural pulse. wear gloves when doing this.
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Now the vascular part of the assessment so we will move out to the extemeties. we need to be able to talk about an orthorstatic blood pressure. how do you do it and why?
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to see the difference b/t the two blood pressures. see the vascular system on meds or with old people, their vascular system is slow to clamp down. See, it doesn't have to work hard while we are laying down, but when we stand up, we need blood going to our brain so our vascular system needs to clamp down to get blood to our brain. this is what makes us dizzy when we stand up.
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so we need to know if they get dizzy when they stand up. If someone is dehydrated and their system does try to clamp down when standing up, what?
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the system doesn't have the volume to make it happen.
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so to check the vascular system we will check for capillary refill times in the toes and finger tips and watch for ...
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how long the color takes to come back after you pinch the finger on each hand and each foot. if there is thick toe nails or nail polish, ck the tip of their fingers and also the same with the toes. this is capillary refill time and should be less than 3 seconds.
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how to document this. say that everything is planned CRT X 4 < 3 seconds. what is crt for?
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capillary refill time
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at the feet we need to check the pedial pulse. are we counting this?
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no. we want to know if its symmetrical and if its palpule
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what is the holman sign. what is it?
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wheither a person has a blood clot in their leg. so they lay down and dorsi flex their foot and ask if they have pain in their calf. this tells if they have a clot there.
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the other pulses we need to be able to find are the
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carodid pulse. locate and identify, identify and talk about it, only ck. on side at a time and do it gently b/c the might have plack in there and shake it loose. and you don't do both at the same time. they could black out.
Radial pulse the femeral pulse in the groin, a deep strong pulse |
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the popleitel pulse is where
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behind the knee, a very deep pulse but find a good pedial pulse, you know circulation is getting down there. the pedial pulse is top of the pulse.
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where is the post tibial pulse?
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on the inside, not outside, in the grove b/t ankle bone and the heel.
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assess for CMS. what does this mean?
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color motion sensation.
ck on distal fingers and toes, what could affect this? a cast on somewhere that is cutting off the blood supply. or surgery on a leg, we want to do CMS on that foot. |
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doing assessments on feet we look for what?
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edema. we would only document the presence and location. we would not document any pitting or number. just that it is there. Pitting means if you press down, it leaves a pit.
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if laying in bed, the edema will do what?
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sink to the bottom of the foot, the heel area, so look there if they are laying in bed.
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for our check off, the check off will be the general mobility, range of motion, what else...
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can they stand by themselves,
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DOCUMENTATION (cont.)Karla
Always use black ink its always part of the permanent record if it goes to court, it ... |
will be there too.
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spelling, any documentation represents the credibility of you. what crediblility do you have if you cant spell a simple medical term like sterile?
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none a jury would wonder what other mistakes you made
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fill out in narrative style on charts, use medical terms,
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so punctuation and spelling is important.
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narrative style charting examples. charting for an assessment.
A & O X 3 means ... |
alert and oriented times 3
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PERRLA means ...
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PUPILS ROUND REACTIVE to LIGHT ACCOMADATION
PUPILS are equal PUPILS are round PUPILS react to light ACCOMODATION=s/b dirct & concentual |
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the skin was warm, pink, mosit..
lungs c / a line above it crackles in bases ant. & post. |
lungs with crackles in bases and posterior
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HR 80 & reg
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heart rate is 80 and regular
this should say what kind of heart rate, like aprial HR |
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abd c / line above it active bowel sounds, mildly distended, firm s with a line above it ...
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abdomen w/ active bowel sounds mildly distended firm without tenderness to light palpation.
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well healed midline incision extending from umbilicus to pubis.
crt < 3 sec X 4 |
capillary refill time 3 seconds times 4
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0 edema (a zero w/ a line thru it) homains bilat
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zero edema , negative holman bilaterially
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pedial pulse palpable & equal bilat.
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pedial pulse palpable and equal bilaterally.
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amb to BR c w/ a line above it walker
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ambilatory to bathroom walker
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& SBA s w/ a line above it difficulty
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and stand by assist without difficulty
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to study this particular skill is to read nursing notes. also ...
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ask the instructor for his imput on this
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A sample assessment given by Karla!
To Mark, can you tell me your name can you tell me who these people are do you know where you are today can you tell me the date so what can we say about mark's orientation? |
he's alert , eyes open, he is responding correctly so he is A&O X 3. it means alert and oriented in all three areas, PERSON, PLACE, & TIME.
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mark, i just want to shine a light in your eye. just gaze over my shoulder. now look over to that far corner. make sure about the light for accomodation. why
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so the light will restrict. it won't restrict if they are already resticted b/c of bright light in the room.
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so why he's doing this, i can observe his skin at this time. his skin has stat return. what does that mean?
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his skin returned from the pinched 'tent' immediately.
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his skin is pink and warm and dry and had stat ...
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return
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now we do the chest.
Mark, are you a smoker? no how long have you quit? ] I am now going to ask you to take some deep breathes. how many lobes on each side? |
left has 2 lobes
righ lung has 3 lobes so, this is like asking a patient to hyperventilate so tell them if to let you know if they start to get dizzy! |
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never listen against a flat bone like the ...
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scapulla. so we go in big curves around and side to side and down. its a cross down. this it to compare each side to each other.
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now Karla listened to the front chest. be consiously watching your patient for dizziness. Please take a deep breath,...
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go around the bones in the front top to bottom, comparing left to right and then work down.
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a thin person use a peds diaphram, if you can see their ribs use peds diaphram. 5 - 9 steps here, and don't listen right on top of the ...
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rib itself. use a good seal but don't press too tightly just make sure the diaghram has a good seal. this is a problem w/ thin people.
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we now go to the heart. we listen to S2 first. she could listen to 4 but she will only listen to 2, S1 and S2 and its going to be ...
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S2 first. why? b/c that's the first one to go down. so find manubrium then 2nd intercostal space out left side 2 " and then just listen to S2. the 2nd sound is emphasized.
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now go down from 2nd intercostal space, mid clavicular lihe is where you will count the ...
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aprical heart rate.
she can hear the emphasized S1 sound has first sound emphasized and counted for a full minute. |
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what is the second important observation about mark's heart rate?
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its rhythm. its regular.
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you only count a full 60 seconds on a aprical pulse. the S1 aprical pulse you ONLY count the full minute.
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we have 2 valves in S1 and S2. so listen to S2 first, if you go the right side, you will hear the aortic and the left side the pulmonic. But we won't be doing that!
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how can you hear both valve sounds for S1?
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go to the 4th intercostal space right at the sternum border which is the tricuspid
go to the 5th intercostal space, midclavicular which is the mitral valve S1 sound. She wants us to ck. the S1 at the mitral valve or midclavicular line! But regardless what you do here, it won't affect the rate. |
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now to look at stomach. mark do you have any tender spots on your stomach? ok. i look for anything abnormal like...
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scars, lumps/bumps, anything unusual, remember NEVER put down something subjective like "there is an appendectomy scar" b/c won't don't know what the hell that scare is even if they say what it is! so start right lower quad. its the ileum/secum area and most active.
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she then palpates the tummy with her fingers in gentle circles, looking for anything that stands out . it should be ...
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soft and flat. don't wear gloves. don't want to feel any regididy,
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now to move to his extremities, could ck his femeral pulse now w/ gloves on. we now do a CRT what is that?
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capillary refill time. s/b 3 " or less. do this on finger nails and toe nails. look for edema along tibia on top of the foot and behind the foot b/c fluids will go there b/c of gravity, esp.if laying in bed alot.
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now ck the holman for clots so do a doriflex and ask for any pain ...
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in the calf. pain would indicate a clot. don't confuse this w/ planter flex, that pointing your toes like a diver. don't need to palpate w/ gloves except femural pulse.
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are we counting when we feel the pedal pulse?
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no , looking for symmentry only. if both sides are the same pulse power. that it is palpable and equal.
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now ck the holman for clots so do a doriflex and ask for any pain ...
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in the calf. pain would indicate a clot. don't confuse this w/ planter flex, that pointing your toes like a diver. don't need to palpate w/ gloves except femural pulse.
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are we counting when we feel the pedal pulse?
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no , looking for symmentry only. if both sides are the same pulse power. that it is palpable and equal.
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