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Assessment

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Assessment CHAPTER 12 N.F. Purpose of Assessment Is the systematic examination of the body Assessment is the 1st step in the Nursing Process It s a method of ... – PowerPoint PPT presentation

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Title: Assessment


1
Assessment
  • CHAPTER 12
  • N.F.

2
Purpose of Assessment
  • Is the systematic examination of the body
  • Assessment is the 1st step in the Nursing Process
  • Its a method of gathering objective data about
    your pt

3
Physical Assessment
  • Can also help to detect early signs of developing
    health problems
  • It establishes a baseline for future comparisons
  • It allows for evaluation of the pts response to
    medical and nursing interventions
  • Physical Assessment uses all the senses except
    taste

4
Focused Assessment
  • While performing a whole body assessment, the
    nurse can look closer at specific parts of the
    body to gain more needed information
  • For example, if a pt states that he has tingling
    in his left foot, the nurse can further test the
    nerves in that area and try to be more specific
    as to why the pt has tingling. She understands
    that nerves may be related, she is using a more
    holistic assessment

5
Gathering Information About The Patient
  • 1. Nurses must 1st obtain a health history we
    need to get all past surgeries, medications,
    conditions in order to eventually treat the
    person as a whole
  • 2. We need to obtain personal data such as
    address, who the pt lives with, emergency contact
    numbers and names, religion. All of this will
    help to add to the persons health history, so we
    can treat the whole person

6
Gathering Info.
  • 3. Ask why the pt is here and ask what their
    symptoms are
  • 4. Family hx, this may help us answer questions
    about current medical condition
  • 5. Life styles and habits may also tell us info.
    That will aid in planning for the outcome and
    care of the pt, do they have help at home, who
    will assist with insulin, does the pt have health
    ins. To have homecare nurse come to the house

7
Gathering Info.
  • 6. Along with current signs and symptomswe need
  • Vital signs, wt and ht

8
Signs Symptoms
  • SIGNS are what others observe this is objective
  • SYMPTOMS are what the pt states - this is
    subjective

9
Prodromal signs symptoms
  • Prodromal pertains to the initial stage of a
    disease the interval between the earliest
    symptoms and the appearance of a rash or fever
  • Prodromal SS are noticed before an illness is
    obvious

10
Vital Signs
  • As part of physical assessment, we always obtain
    a set of vital signs before we start assessing
    the physical body
  • T P R BP- Pain
  • (remember the norms)
  • Pain is now the 5th vital sign

11
Temperature
  • Remember to use the blue tip for oral and the red
    tip for rectal
  • Always apply a sheath onto the tip for pt
    protection
  • Always use surgical lubricant on the tip of a
    rectal thermometer
  • Normal temp 36.4 37.7
  • 38.0- eyebrows 38.5 febrile call Dr.

12
Pulse
  • Heart rate
  • Listen to the apical heart beat for 1 full minute
  • Normal HR for adults 60-100
  • Normal HR for newborns - 120-160
  • Can use other sites for pulse rate, radial is
    most popular

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18
Respiratory Rate
  • Normal rate is 12-20

19
Blood Pressure
  • Remember to use the correct sized cuff
  • Normal B.P. 120/80
  • Pressure that needs medication 150/90

20
Postural Hypotension (AV)
21
4 Basic Physical assessment Techniques
  • These have been discussed in Skills Lab
  • 1. Inspection
  • 2. Percussion
  • 3. Palpation
  • 4. Auscultation

22
Inspection
  • Most frequently used assessment
  • Need time, good lighting and you must know the
    norms of a pt.
  • It involves examining particular parts of the
    body, many senses are used to scan the pt

23
Percussion
  • The least used Nursing Technique
  • Drs. use this more, mass is dull or over the
    liver, lungs and abdomen are air filled and
    hollow
  • This technique is when you strike or tap a part
    of the body with the finger tips to produce
    vibratory sounds. The quality of the sound aids
    in determining the location, size and density of
    underlying structures

24
Palpation
  • Is lightly touching or applying pressure
  • Palpations provides info, about
  • Size, shape and consistency and mobility of
    normal tissue, skin temp, tenderness if any
  • Pt should be relaxed , warm hands, short nails,
    gentle touch

25
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26
Skin Temperature (AV)
27
Auscultation
  • Listening to body sounds, is a frequently used
    assessment technique
  • We auscultate heart, lungs and abdomen
  • A stethoscope is required
  • We also listen to bowel sounds of the G.I. Tract
  • Must not have much background noise or sounds
    will be misinterpreted

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There are 2 ways to assess your pt
  • 1. A nurse can use the head-to-toe approach
  • - Or -
  • 2. The body systems approach
  • Either system works and you should pick one that
    you like and ALWAYS use the same approach as to
    not forget a system

30
Sensory
  • You are trying to get information on the
    appearance and function of sense organs plus a
    mental response
  • You are looking at the eyes, ears, nose,
    mouthalso the skin, oral and nasal mucous
    membranes, hair and scalp

31
Opthalmoscope
32
Ears
  • Should contain a small amount of soft cerumen.
  • Blood or clear spinal fluid should not be
    present
  • Some people produce larger amounts of cerumen
    than others

33
Ears
  • Pts may experience tinnitus ringing in the ears
  • Can be caused by otis media (ear infection) or by
    impacted cerumen. May also be caused by
    medications like an overdose in Tylenol

34
Mental Status
  • You are trying to determine the level of a pts
    cognitive functioning, this is
  • Concentration
  • Memory ask pt what the day and date are and who
    is the presidenteasy questions
  • For most pts, documenting that the pt is alert
    and oriented is all that is necessary, check if
    they are AO x3 (this is to person, place , time)

35
If pt is
  • A head injury pt
  • Were recently resuscitated
  • Were recently confused
  • Took an overdose
  • Have a hx of alcoholism or
  • Have a psych diagnoses
  • Then more objective info is needed from you.
    They may not be able to tell you things or answer
    your questions, you must just observe this

36
Neuro checks
  • Determines a patients mental status
  • Besides checking pupils and mental status (AO x
    3), must check motor skills like sticking out of
    tongue and moving it, and check grasp strength
  • Have pt squeeze your fingers to determine how
    strong they are and if the strength is equal on
    both sides
  • Have pt push and pull with legs and feet
  • Have pt move around room, walking to check their
    gait or mobility and walking, is pt unsteady?

37
What to do if pt is not waking up or you want to
be certain they are unresponsive?
  • Sternal rub make a fist and gently but firmly,
    rub up and down briefly using knuckles. If pt is
    conscious, he will awaken immediately

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39
Muscle strength (AV)
40
Gait
  • You want to see if pt can walk and how steady
    they are on their feet

41
Gait (AV)
42
Speech
  • Some pts cant speak well, as part of the
    neurological assessment, speech must be assessed
  • If stroke or brain damage has occurred, pt may
    have aphasia
  • Next slide for def. of aphasia

43
Aphasia
  • Absence or impairment of the ability to
    communicate through speech, writing, or signing
    because of the brains dysfunction

44
Expressive Aphasia (AV)
45
Hair
  • Inspect the hair for lice or scalp lesions

46
Assessment of hair includes
  • Scalp
  • Eyebrows
  • eyelashes

47
Vision - Eyes
  • You are looking at the external structure and
    appearance of the eyes
  • Is the pupil round and responsive
  • Is there discoloration, crusting, tearing,
    swelling, secretions or bilateral movement?
  • You will chart PERRLA
  • PERRLA is

48
PERRLA
  • Pupils Equally Round and React to light
  • and accomodation
  • which is the ability to constrict when looking at
    a near object and dilate when looking at an
    object in the distance

49
Pupil Response to Light (AV)
50
Retina
51
Visual Fields Test
  • This exam is to determine if the pt has
    peripheral vision
  • It can be done simply or more in depth. Nurses
    can have pt look straight ahead while she/he
    moves an object near the temporal area of the
    head and asks the pt if they can see the object
    while looking forward. Some neurological
    disorders are associated with changes in the
    visual field

52
Snellen Chart
53
Pediatric Eye Chart
54
Mental Status
  • Normal Alert and Oriented X3
  • Oriented to
  • 1. Self (person)
  • 2. Place
  • 3. Time

55
Hearing and Ears
  • Nurse checks the appearance of the outer ear,
    looking for any discharge in the ear
  • An otoscope is used examine the tympanic membrane
    (ear drum)
  • Be sure to check behind the ear for tenderness

56
Hearing and Ears
  • If pts have a hearing aid for amplifying sound,
    the nurse notes this in the nursing record
  • An standard audiometry is a sophisticated test to
    identify a persons range of hearing by measuring
    hearing acuity at various sound frequencies

57
Hearing and Ears
  • The Weber and Rinne test uses a tuning fork
  • This test is used to determine if pts have
    hearing impairment as a result of sensory nerve
    damage or disorders that interfere with sound
    conduction through the ear

58
Otoscope
59
Mouth and Oral Mucous Membranes
  • Check lips and mouth and teeth for abnormalities
  • Nurse documents dentures, malpositioned teeth or
    a partial plate
  • Odor of breath can be an indicator of illness

60
Facial Skin
  • When assessing the head, skin on face and neck
    should be included
  • Skin should be smooth, unbroken, uniform color,
    warm
  • Skin should feel neither wet or dry
  • You are looking for wounds, ulcers, abrasions,
    lacerations, fissures or scars
  • Check moles for color, size and shape

61
Skin Tone - TURGOR
  • You check turgor by pinching up on the skin of
    the hand or usually the forearm
  • Skin should rebound (go back to normal)when
    lifted, dehydrated skin will not do this
  • Edematous skin may stay in the Squeezed up
    state too

62
Dehydration
63
Edema (AV)
64
Pitting Edema
65
Pitting Edema
66
Total Body Skin
  • When you first greet your pt, you can see the
    condition of the skin on their face, arms if they
    have a short sleeved shirt on and possibly legs
    if wearing a skirt or shorts

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Skin Color Abnormalities
  • Cyanosis bluish skin color from poor perfusion
    of tissue
  • Jaundice yellowish skin tones from bile
    pigments in the skin related to red blood cell
    destruction or G.I. Disorders related to liver
    and gallbladder
  • Pallor pale colored skin as in anemia

69
Check nail beds
  • Looking for cyanosis and capillary refill time
  • Should be less than 3 seconds when you press on
    the fingernail bed

70
Capillary Refill (AV)
71
Check the legs
  • It is a good time to assess the skin on the lower
    legs and to check for the Homans sign

72
Homans Sign (AV)
73
Common Skin Lesions
  • Inspect the skin for
  • Wound break in the skin
  • Ulcer crater like lesion
  • Scar left after healing of wound
  • Fissure groove or crack

74
Drainage
  • Sanguineous contains blood
  • Serosanguineous contains blood and clearish,
    watery serum
  • Mucoid mucus
  • Purulent pus
  • Mucopurulent contains pus and mucus

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76
Erythema
77
Ecchymosis
78
Mottling
79
Flushing
80
Scarlett Fever-Circumoral Pallor and Flushing of
Cheeks and Strawberry Tongue
81
Necrosis
82
Jaundice
83
Newborn Jaundice
84
Jaundice
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88
Abrasion
89
Chest shape and movement
  • With normal breathing, the chest moves
    symmetrically
  • Musculoskeletal abnormalities, cardiac or
    respiratory diseases or trauma can cause changes
    in chest shape

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91
Spine
  • The spine or vertebral column should remain
    midline with gentle concave and convex curves
    when viewed from the side
  • The shoulders should be at equal height
  • Lordosis lumbar curve
  • Kyphosis thoracic curve
  • Scoliosis lateral curvature of the spine
  • The abnormalities can be detected in assessment

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Damage to the spine or brain
  • A condition known as posturing occurs
  • See next slide -?

94
Decerebrate
95
Decerebrate
  • Arms are like the letter e
  • Problems within midbrain or pons in the brain

96
Decorticate
97
Decorticate
  • Arms or like a C
  • Problems with cervical spinal tract or cerebral
    hemisphere

98
Breasts
  • Tumors are seen more in women but can occur in
    men
  • Breast exams are usually performed by the
    advanced practitioner
  • Much information is available in the form of
    pamphlets on self breast exams. Physicians
    usually teach this when examining a women
  • Nurses have the role of educating women on how
    often to examine their breasts, nurses should
    teach that its a monthly exam

99
Heart Sounds
  • Heart sounds are sounds of the closing of the
    atrial and ventricular heart valves
  • New nurses limit their exam to just listening to
    the apical area, advanced nurses are able to
    detect specific areas of the heart

100
Explanation of heart sounds
  • We discussed the sounds in lab as lub-dub
  • This lub-dub 1 heart beat
  • They label these lub-dub sounds as
  • LUB S1 closing of tricuspid and mitral valve
  • DUB S2 closing of pulmonic and aortic valve

101
Why name these heart sounds
  • Labeling these lub-dubs with S1, S2, S3, S4
    allows other caregivers to easily recognize and
    treat cardiac pts. in a consistent way

102
Tabers
  • Defines S1 and S2 as normal first and second
    heart sounds
  • Defines S3 as Ventricullar gallop or abnormal
    heart sound
  • Defines S4 as Atrial gallop and abnormal heart
    sound

103
Apical Pulse
104
Apical Pulse
  • Remember to listen to the apical for 1 full
    minute, especially if trying to hear the hrt rate
    is difficult

105
Apical Pulse (AV)
106
Lung sounds (AV)
107
Normal Lung Sounds
  • Are created by air moving in and out of air
    passageways
  • These sounds vary in pitch and duration (length)
    There are 4 normal lung sounds

108
4 Normal Lung Sounds
  • Tracheal Sounds loud coarse
  • Bronchial Sounds harsh loud
  • Bronchovesicular Sounds med. Range sounds
  • Vesicular Sounds soft, rustling sounds
  • The type of sound depicts their location

109
How do we listen to lung sounds from the front
(Anterior)
  • 1. We usually start at the pts upper right chest
  • 2. Slide over under the neck line to the left
    side comparing the sounds
  • 3. Slide downward staying on the left side of the
    chest and listen, then slide over to the right
    and listen, then down the right and listen, then
    over to the left and listen
  • 4. We do this 5xs on each side until we reach
    under the nipple or pectoralis muscle. This 5xs
    method allows us to hear all lung fields

110
How we listen to lung sounds from the side
(lateral)
  • 1. Listen under the axilla area, in line with the
    nipple but on the side of the body
  • 2.Move downward a few inches
  • 3.Move slightly toward the front of the body
  • 4.Then move towards the back a bit

111
How we listen to lung sounds from the back
(posterior)
  • 1. Start up at the top right of the back just
    below the neck on either side of the vertebral
    column
  • 2. Slide over to the left, slide down the left
    and then over to the right, staying between the
    scapula
  • 3. Continue sliding downward and moving left to
    right until you reach below the nipple line (if
    you could see through the body)
  • You are listening over the rib cage, once you
    reach the bottom of the ribs, you are done

112
Abnormal or Adventitious Sounds
  • These are sounds heard along with the normal lung
    sounds. Most of the adventitious sounds are due
    to air moving through secretions or narrowed
    airways. They are
  • Crackles
  • Rhonchi or gurgles
  • Wheezes
  • Rubs

113
Crackles
  • Also known as rales
  • Crackles are high-pitched popping sounds heard on
    inspiration
  • Sound like Rice Crispies and milk

114
Rhonchi or gurgles
  • Low pitched continuous bubbling sound heard in
    the Bronchi (large airways)
  • Heard during expiration
  • Sounds like wet snoring

115
Wheezing
  • Whistle or squeaking sound, heard on inspiration
    and expiration
  • heard through narrow passageway
  • Doesnt clear with coughing, if wheezing stops,
    complete occlusion is happening
  • asthmatics

116
Rubs
  • Grating or leathery sound
  • Caused by 2 dry pleural surfaces moving over each
    other

117
When adventitious sounds are heard
  • The nurse assesses the patient for cough and
    sputum
  • SPUTUM expelled from the mouth from the
    respiratory tract, it is thicker than mucus, if
    its yellow or green, means infection. Never
    swallow sputum, needs to be expelled out into
    bucket or Kleenex or sample container

118
Anterior chest Assessment (AV)
119
Respiratory Assessment (AV)
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123
Kussmaul Respirations
  • A very deep gasping type of respirations
    associated with severe diabetic acidosis and coma
  • Breathing is deep for several breaths, then it
    pausesa little different than Cheyne-stokes

124
Cheyne-Stokes
  • Where the depth of respirations gradually
    increases, followed by patterns of gradual
    decrease, and then periods when breathing stops
    briefly, before resuming again.
  • This is seen before death occurs

125
Biots respirations
  • (Bee-oz)
  • These are breathing marked by several short
    breaths followed by long, irregular periods of
    apnea.
  • Biots is seen in pts with increased intrcranial
    pressure
  • Taber says to see Cheyne-stokes respirations

126
Abdominal assessment
  • You are inspecting the skin for sores or other
    skin problems
  • You are palpating the abdomen to see if belly is
    soft or firm, distended or non-distended
  • A Hard, firm, or distended abdomen may indicate
    gas, stool, obstruction or a full bladder

127
Abdominal Sounds
  • As we move down the body, we want to listen to
    the sounds of the bowels
  • These are called bowel sounds
  • These are wave-like muscular contractions of the
    large and small intestines that move fluid and
    intestinal contents toward the rectum
  • Usually ausciltated upon admission and once a
    shift

128
4 Quadrants of the Abdomen
129
Bowel Sounds
  • Normal bowel sounds resemble gurgles or popping
    and occur 5-34 times/minute
  • Hyperactive bowel sounds are overly active and
    loud
  • Hypoactive bowel sounds are weak sounding or
    absent. Must listen for up to 2 minutes if you
    believe bowel sounds are absent and notify the
    Dr.
  • MUST turn off NG suction machine to hear real
    bowel sounds

130
Abdominal Girth
  • Is obtained by measuring the circumference of the
    abdomen using a tape measure and measuring the
    largest diameter of the abdomen.
  • Marking the pts skin with a pen is acceptable to
    ensure that all other staff will measure in the
    same spot
  • Report any increase in girths immediately to RN
    or Dr.

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Genitalia
  • Usually performed by the Dr. or P.A.
  • Wear gloves for this
  • Ask another worker to be present during this part
    of the exam to eliminate the possibility of being
    falsely accused of sexual abuse
  • The nurse inspects the skin for sores and the
    pubic hair for lice

133
Rectum
  • The nurse usually performs a visual exam only.
    The Dr. can examine pt more invasively
  • Full GYN exam or prostate exam can be done by Dr.
  • Nurse looks for presence of hemorrhoids and
    reports this to RN or Dr.

134
What to do with all of the information?
  • Every facility has their own method of recording,
    usually upon admission is when the nurse would
    include ALL of the information we have just
    discussed
  • On a shift-to-shift basis, the assessment is
    scaled down to include T-P-R-BP and some basic
    physical assessement information

135
Nursing Diagnoses
  • Once the physical assessment is completed, the
    nurse is able to highlight the problem areas in
    her brain and locate one or several nursing
    diagnoses in order to be able to apply this to
    the Nursing Process
  • Dont be afraid to use as many diagnoses that
    apply to one pt. He will get holistic care if
    you address all problems

136
CYA
  • NEVER forget to chart
  • If it wasnt written then.

137
THE END
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