Elizabeth M. Long, DNP, APRN, GNP-BC, CNS, 2016 Assessment Review Elizabeth M. Long, DNP, APRN, GNP-BC, CNS, 2016

NCLEX Questions: Client Needs Four Major Categories Safe and Effective Care Environment Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity

Assessment: Nursing Process Assessment is always first step Look at the question Asking nurse to monitor and observe-assessment? Asking nurse to take action?

Example Question describing a client with respiratory issues What assessment would nurse carry out? What intervention would nurse perform?

Assessment and Equipment Always assess patient not equipment first

Assessment: Prioritizing Maslow’s Hierarchy of Needs Physiological Safety Love and Belonging Self-Esteem Self-Actualization

Ask Yourself Normal? Okay? Abnormal? Not Okay?

Delegation Assessment Never delegated to LVN or CNA

Common Words Associated with Assessment Observe Gather Collect Distinguish Identify Display Indicate Describe Differentiate Assess Recognize Detect

Nurses Use Assessment Skills To Obtain baseline data on a client Obtain additional information as a client condition changes To identify and manage a variety of patient problems (actual and potential) To evaluate the effectiveness of nursing care To enhance the nurse-patient relationship and To Make clinical judgments

Assessment Order Inspection Palpation Percussion Auscultation

Abdominal Assessment Inspection Auscultation Percussion Palpation

Inspection Observation Observe with eyes, ears, nose-all your senses Look at color, shape, symmetry, position Use good lighting Done alone and in combination with other assessment techniques

Palpation Light and deep touch Back of hand (dorsal aspect) to assess skin temperature Fingers to assess texture, moisture, areas of tenderness Assess size, shape, and consistency of lesions

Percussion Sounds produced by striking a body surface Produces different notes depending on underlying mass (dull, resonant, flat, tympani) Used to determine size and shape of underlying structures by establishing their borders and indicates if tissue is air- filled, fluid-filled, or solid

Auscultation Listening to sounds produced by body Direct auscultation – sounds are audible without stethoscope Indirect auscultation – uses stethoscope

Final Thoughts Know normal range assessment values for all ages Practice, practice , practice questions