Assessments Fundamentals Unit 7

Assessments Introduction “No two patients are alike” Get to know those terms! Assessment- the process of gathering data

Assessments- What is the difference between objective and subjective? Objective signs are those the nurse can see, hear, feel, smell, or measure Subjective symptoms are those the patient experiences

Assessments Examples of subjective symptoms are… Pain – the most important subjective Sx Sensation produced by overstimulation of special nerve endings It indicates normal body functioning is disturbed Tenderness How is pain measured? Character Intensity Location Duration The preferred treatment will be COMFORT MEASURES FIRST

Assessments Another example of a subjective symptom is… Anxiety Can be objective as well Physiological changes will take place Can anxiety be relieved?

Assessments Why do we perform assessments and exams? Gather baseline data Verify or discount information Monitor progress Evaluate interventions Encourage preventive care

Assessments What is contained in a Medical Hx? Past illnesses, surgeries Family History Habits What is the history of the present illness?

Assessment Review of Symptoms: General Appearance Skin Skeletal Head Endocrine Respiratory Cardiac Hematological Genitourinary Neurological Psychiatric

Assessments First we observe… 4 Basic Assessment Techniques… Inspection Palpation Auscultation Percussion

Assessment Inspection-the process of performing deliberate, purposeful, observations in a systematic approach. Uses the senses of smell, hearing and sight Take your time and really look at your patient!

Assessment Palpation-uses sense of touch. Hands and fingers are sensitive tools and can be used to assess temperature, texture, moisture, pulsations, vibrations, shape, masses, and organs Light Palpation-less than 1 cm Deep Palpation- 2.5 to 5 cm

Assessment Percussion-the act of striking one object against another to produce sound. Used to locate shape, size, and density of underlying structures and tissues

Assessment Auscultation- the act of listening with the stethoscope to sounds produced within the body Used for heart, lung, bowel and blood pressure

Assessments- What kind of equipment is needed for an exam? Cotton tipped applicator Tongue blade Flashlight Gloves Stethoscope Otoscope Opthalmoscope Snellen chart Tuning fork Percussion hammer

Assessments What types of positioning can be used during the “A”? Dorsal recumbent Lithotomy Knee-chest or genupectoral Sim’s Supine Prone Lateral recumbent Fowler’s

Assessments What responsibilities will I need to learn to assist with or do the assessment? Equipment Preparation emotionally Preparation physically Positioning Assist the patient Reassurance Assist the examiner End of exam Equipment, specimens Documentation

Assessments Types of Physical Assessments: Admission Assessment Initial, Shift, or Head to Toe Assessment

Assessments Focused Assessments Neurological BP LOC Pupils Motor Glasgow Coma Scale Reflexes Babinski’s

Assessments Focused Assessments Neurovascular (neurocirculatory) Skin color-pink Capillary refill-should be quick Edema-equal bilaterally? Temperature-warm/cool to touch Pulse-palpable? Movement-equal bilaterally? Sensation-can they feel your touch?

Assessments Guidelines for assessing the… Skin Pallor- Lack of color Cyanosis- Bluish discoloration Jaundice- Yellowish discoloration Erythema- Reddened area of skin Mottling- Unevenly distributed bluish or purplish area of skin Necrotic- Gray or black associated with dead or dying tissue

Assessments Guidelines for assessing the… Chest Shape: Funnel Pigeon Barrel

Assessments Guidelines for assessing the… Chest Sounds Crackles-Fine crackling sounds heard on inspiration Rhonchi-Coarse, harsh, gurgling sounds heard on expiration Wheezes-Musical or whistling sounds heard on inspiration or expiration Pleural Friction Rubs-grating sounds usually heard over lower anterior and lateral chest

Assessments Guidelines for assessing the… Abdomen

Assessments Guidelines for assessing the… GU Note if there is a urinary diversion appliance (catheter, ostomy) Note any drainage Note any odor Note any lesions, edema, discoloration

Assessments Guidelines for assessing the… Extremities Equal joint movement Equal pulses Note any pain, redness, or swelling of joint Note any skin lesion

Assessments

Assessments Special Tests and Procedures Pelvic Exam Rectal Exam Proctoscopic Exam Thoracentesis Paracentesis Lumbar Puncture Bone Marrow Aspiration

Assessments Special Tests and Procedures Charting that must be done… Procedure done and by whom Amount, color, and consistency of anything removed Pt. tolerance before, during, and after procedure Any unusual signs observed Vital signs before, during , and after Dressings or bandaids applied If a specimen was obtained and if sent to lab Care or tests after procedure