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Basics Ch 22
| Question | Answer |
|---|---|
| vitally important nursing function; continual process in which the nurse is constantly appraising the condition of patients | assessment |
| Nurses are expected to be able to assess _________ sounds properly, identify abnormal _______________, note skin __________, determine abnormalities and detect neurologic _____________. | lung; heart sounds; problems; changes |
| Good assessment skils can quickly identify: | new signs and symptoms that indicate complications of an illness or advers side effects of medical therapy. |
| Part of assessment that is performed on an almost continual basis. | data collection |
| Initial detailed assessment on admission includes: | physical examination; history and demographic data; information pertinent to dail care; current health problems |
| Nurses must be aware of how the illness is affecting the patient's life. Not only their health, but all other areas such as: | cultural preferences and health beliefs (child care, support system, religion - for blood transfusions, etc.) |
| Questions during assessment should be asked in a: | positive, non-threatening way |
| The initial or admission assessment should include an interview to determine: | social data, marital status, occupation, visual or hearing deficits, dentures, prostheses, allergies (food, drug or other), medications being taking (including OTC and herbal supplements) |
| Other things to include in the initial assessment are: | diet (any limitations or special foods), smoking, alcohol use, ADLs, previous surgeries, health problems (current and past), reason for admission |
| Physical data collected in the initial assessment are to include assessing the: | head and neck; chest, heart, and lungs; abdomen; genitourinary system; extremities and musculoskeletal system; endocrine system |
| 4 tools of physical assessment: | observation, palpation, percussion, auscultation |
| provides a complete picture of physiologic functioning; includes all systems of the body | comprehensive, in-depth assessment |
| confined to a specific body part or system | brief, or scanning type of examination |
| Observation: inspect visually the various parts of the body and the behavioral responses of patients. Visual observation of: | general appearance; contours of the body; skin tone and color, rashes, scars, lesions; deformities or extremity weakness |
| Palpation: Performed using the hands and fingertips to touch and feel various parts of the body. Used to ascertain: | size, shape, and position of body parts; texture, temp, and moisture of skin; presence of muscle spasm or rigidity; pain, tenderness or swelling; presence of growth; restriction in body part movement; skin temp and turgor; presence of edema |
| If palpating and the patient is in pain - | stop and tell the doctor. |
| Percussion - light, quick tapping on the body surface to produce sounds; variations in the sounds reflect characteristics of organs or structures below the surface. Helps in determining: | size, location, and density of organs; presence of air or fluids in tissue or in a body cavity |
| Percussion is used: | primarily overt the chest and abdomen to determine the size, location, and density of organs that lie within |
| Auscultation: listening to presence or absence of body sounds using stethoscope. Particularly useful for: | lung sounds (using the diaphragm of stethoscope); heart sounds (use diaphragm of steth. for normal S1-S2 and to count heart rate - use the bell for some abnormal heart sounds); abdomen (bowel sounds) |
| The diaphragm of a stethoscope is used to detect high-pitched sounds such as: | lung sounds, normal heart sounds, and bowel sounds. |
| The bell of the stethoscope is used to detect low-pitched sounds such as: | abnormal heart sounds made by the valves (heart murmurs) |
| Olfaction: using the nose to identify odors, characteristics of certain problems, such as: | breath odor for sweetness, acetone, or alcohol; wound odors; odors from discharges such as vaginal infections |
| Height and weight - weigh adults without __________. Weigh infants without ___________. | shoes; diaper |
| Assess for these things on head and neck: | general appearance; appearance of the eyes; condition of the hair; difficulty in hearing or seeing; pupils equal in size and accommodated to light; corneas clear (or opaque) |
| Eyes: | PERRLA - pupils equal round reactive to light and accomodation |
| Chest, heart, and lungs: | Chest symmetric? Shoulders at equal height? Any lordosis, kyphosis, or scoliosis? Any signs of dyspnea? Noticeable PMI (point of maximal impulse)? Heart sounds normal? Apical pulse rate normal? |
| Lung sounds - location to listen: | over the trachea; over the upper area of the chest; over the central chest and back |
| Lung sounds - listen for: | vesicular; bronchovesicular; adventitious (abnormal sounds) |
| Tracheal breath sounds should be: | loud and coarse, equal in length for inspiration and expiration and have a light pause between them |
| Bronchial breath sounds should be: | harsh and loud, shorter on inspiration and a pause between the two sounds |
| bronchovascular sounds should be: | medium in tone and loudness, equal in length during inspiration and expiration |
| vesicular sounds: | soft, rustling sounds heard in the periphery of the lung fields, longer on inspiration and no pause between them |
| adventitious sounds: | abnormal lung sounds |
| whistling, musical, high-pitched sounds produced by air being forced through a narrowed airway | wheeze (asthma and COPD) |
| coarse, low-pitched, sonorous, rattling sounds caused by secretions in the larger air passages | rhonchi |
| fine or coarse sounds, similar to sound produced by rubbing hairs between the fingers close to the ears | crackles |
| craoking sound heard when there is partial obstruction of the upper air passaages - heard withoud stethoscope | stridor |
| When assessing for chest rising and falling _____________ on both sides of the body. | symmetrically |
| Respiratory patterns: | eupnea; tachypnea; bradypnea; Kussmaul's; apnea; Cheyne-Stokes |
| breathing in and out normally | eupnea |
| breathing fast | tachypnea |
| breathing slowly | bradypnea |
| labored and loud (normal when in final stages of dying) | Kussmaul's |
| stops breathing | apnea |
| Inspect skin for: | rashes and lesions; flaking or dryness; signs of dehydration or edema (shoe, sock or ring tightness); turgor; capillary refill (less than 3 seconds); assess peripheral pulses |
| yellow-orange color that may be noted in the pt's sclera, mucous membranes or skin | jaundice |
| bluish skin caused by low oxygen levels - will be noted in the nail beds, lips, base of tongue,and skin | cyanosis |
| Areas of the skin that become swollen or edematous from fluid buildup in the tissues; assessed by pressing the fingers into the tissue over the tibia just above the ankle | dependent edema |
| two major causes of dependent edema | direct trauma; impairment of venous return |
| indentation that remains after assessing for edema | pitting edema |
| 1+ pitting edema | slight pitting with 2 mm indentation that disappears rapidly with no visible extremity changes |
| 2+ pitting edema | deeper pitting with 4 mm of indentation that disappears in about 10-15 seconds with no visible extremity changes |
| 3+ pitting edema | 6 mm indentation that lasts more than 1 minute. Visible edema on extremity. |
| 4+ pitting edema | very deep pitting - 8 mm indentation; lasts 2-3 minutes; extremity has gross edema |
| Bowel sounds should be assessed in all four quadrants on admission. Bowel sounds are: | normal, hypoactive, hyperactive, or silent |
| Normal bowel sounds: | 5 to 30 sounds/min |
| hypoactive bowel sounds: | slow, sluggish (ex. - after surgery) |
| hyperactive bowel sounds: | occur with nausea, vomiting, diarrhea |
| silent bowel sounds: | no sound; ausculate for 5 minutes in each quadrant |
| Assess abdomen for distention or tenderness. | |
| When assessing the abdomen, always inspect firs, ____________ second, and ____________ last. | ausculate; palpate |
| Unless pt has a specific complaint in these areas, the nurse does not visually assess them; may be assessed when bathing the pt, performing perineal care, or assisting with toileting; as pt if any problems in this area | genitalia, anus, and rectum |
| Assessment of the Areas of Basic Needs | RNSHOPE (Rest and activity, Safety and security, Hygiene, Oxygenation, Psychosocial and learning, Elimination) |
| when specific body part is being assessed; if a pt complains of abdominal pain, a focused assessment on the abdomen would be done | focused assessment |
| Neurologic check | performed at regular intervals on pts who have had a head injury or brain surgery; pupil size is measured; pt asked to track the nurse's finger or object as moved to six different positions; Glasgow Coma Scale is used in most hospitals to score neuro exam |
| Glasgow Coma Scale | Pg. 392 |
| Also do neurocheck and Glasgow when pt falls | |
| Evaluation questions | Were all areas assessed adequately? Any data missing from assessment form? Pt comfortable during assessment? All equipment available for exam? Pt positioned and draped properly? Procedures and purposes explained to pt? |
Created by:
akgalyean
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