Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Bedside Assessment of the Hospitalized Adult Chapter 28

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Reassessment of the Hospitalized Adult  In hospital setting:  Patient does not require a complete head-to-toe physical examination during every 24-hour stay Patient does require consistent specialized examination at least every 8 hours that focuses on certain parameters Patient does require consistent specialized examination at least every 8 hours that focuses on certain parameters Note that some measurements, such as daily weights, abdominal girth, or circumference of a limb, must be taken very carefully Note that some measurements, such as daily weights, abdominal girth, or circumference of a limb, must be taken very carefully Usefulness of such measurements depends entirely on consistency of procedure from nurse to nurse Usefulness of such measurements depends entirely on consistency of procedure from nurse to nurse Also remember that many assessments must be done frequently throughout course of a shift Also remember that many assessments must be done frequently throughout course of a shift Slide 28-2

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Reassessment of the Hospitalized Adult (cont.)  In hospital setting:(cont.)  In hospital setting: (cont.)  Outline of initial assessment As you perform this sequence, take note of anything that will need continuous monitoring, such as a blood pressure or pulse oximetry reading that is not what you expect, or breath sounds suggesting difficult respiratory effort As you perform this sequence, take note of anything that will need continuous monitoring, such as a blood pressure or pulse oximetry reading that is not what you expect, or breath sounds suggesting difficult respiratory effort If there is no protocol in place for a particular assessment situation, then decide for yourself how often you need to check on person’s status If there is no protocol in place for a particular assessment situation, then decide for yourself how often you need to check on person’s status  It is very easy to be distracted by ringing bells and alarms as shift progresses, but your judgment about patient needs is just as important as any electronic alert or alarm Slide 28-3

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Reassessment of the Hospitalized Adult(cont.) Reassessment of the Hospitalized Adult (cont.)  In hospital setting(cont.)  In hospital setting (cont.)  Outline of initial assessment Your assessments must be thorough and accurate, yet you must be able to complete them rapidly without seeming hurried Your assessments must be thorough and accurate, yet you must be able to complete them rapidly without seeming hurried Basic reassessment applies to adults in medical, surgical, and in cardiac step-down care areas Basic reassessment applies to adults in medical, surgical, and in cardiac step-down care areas Each assessment must then be specialized to each adult, and findings must be integrated into your complete knowledge base regarding patient Each assessment must then be specialized to each adult, and findings must be integrated into your complete knowledge base regarding patient This includes what you read in chart, what you hear in reports, and results of any laboratory tests and diagnostic imaging that are available This includes what you read in chart, what you hear in reports, and results of any laboratory tests and diagnostic imaging that are available Slide 28-4

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Health History  On your way into room  Note and verify that necessary markers or flags are in place at doorway regarding such conditions as isolation precautions, latex allergies, or fall precautions  Once in the room  Introduce yourself as patient’s nurse for next 8 hours  Make direct eye contact and ask how he or she is feeling, how he or she spent previous shift, and if he or she is having any pain or discomfort Slide 28-5

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Health History(cont.) Health History (cont.)  Once in the room (cont.)  Refer to what you have heard from previous shift in process of your own questioning This alleviates person’s frustration at answering same questions every time a new staff member enters This alleviates person’s frustration at answering same questions every time a new staff member enters Offer water as a courtesy and note data this gives you Offer water as a courtesy and note data this gives you  Person’s ability to hear, follow directions, cross the midline, and especially ability to swallow As you collect this and subsequent history, note data on general appearance As you collect this and subsequent history, note data on general appearance Complete your initial overview by verifying that correct name band has been applied to wrist Complete your initial overview by verifying that correct name band has been applied to wrist Slide 28-6

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Objective Data  General appearance  Facial expression, appropriate to the situation  Body position, relaxed and comfortable or tense, in pain  Level of consciousness, alert and oriented, attentive to your questions, responds appropriately  Skin color, even tone consistent with racial heritage  Nutritional status, weight appears in healthy range, even fat distribution, hydration appears healthy Slide 28-7

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Objective Data(cont.) Objective Data (cont.)  General appearance (cont.)  Speech: articulation clear and understandable, pattern fluent and even, content appropriate  Hearing: responses and facial expression consistent with what you have said Slide 28-8

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Objective Data(cont.) Objective Data (cont.)  Measurement  Temperature  Pulse  Respiration  Blood pressure  Pulse oximetry  Rate pain level on 1 to 10 scale, pain tolerance  If pain medication given, note response in 15 minutes for IV administration to 1 hour for oral administration Slide 28-9

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Objective Data(cont.) Objective Data (cont.)  Neurologic system  Eyes open spontaneously to name  Motor response  Verbal response  Pupil size in mm and reaction, right and left  Muscle strength, right and left upper; right and left lower  Any ptosis, facial droop  Sensation  Communication  Ability to swallow Slide 28-10

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Objective Data(cont.) Objective Data (cont.)  Respiratory system  Oxygen by mask, nasal prongs, check fitting  Note FIO 2  Respiratory effort  Auscultate breath sounds comparing side to side  Ask patient to cough and deep breathe; any mucus? Check color and amount Check color and amount Slide 28-11

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Objective Data(cont.) Objective Data (cont.)  Cardiovascular system  Auscultate rhythm at apex: Is it regular?  Check apical pulse against radial pulse, noting perfusion of all beats  Assess heart sounds in all auscultatory areas: first with diaphragm, repeat with bell  Check capillary refill for prompt return  Check pretibial edema  Palpate posterior tibial pulse, right and left Slide 28-12

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Assess Heart sounds Slide 28-13

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Objective Data(cont.) Objective Data (cont.)  Cardiovascular system (cont.)  Palpate dorsalis pedis pulse, right and left Note: Be prepared to assess pulses in lower extremities by Doppler imaging if you cannot find them by palpation Note: Be prepared to assess pulses in lower extremities by Doppler imaging if you cannot find them by palpation  Verify that the proper IV solution is hanging and flowing at the proper rate according to the physician’s orders and your own assessment of the patient’s needs Slide 28-14

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Objective Data(cont.) Objective Data (cont.)  Skin  Note skin color, consistent with person’s racial heritage  Palpate skin temperature; expect warm and dry  Pinch up a fold of skin under clavicle or on forearm to note mobility and turgor  Note skin integrity, any lesions, and the condition of any dressings  Complete any standardized scales used to quantify risk of skin breakdown Slide 28-15

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Objective Data(cont.) Objective Data (cont.)  Skin(cont.)  Skin (cont.)  Verify that any air loss or pressure loss surfaces being used are properly applied and operating at correct settings  Abdomen  Assess contour of abdomen: flat, rounded  Listen to bowel sounds in all four quadrants  Check any tube placement for drainage and insertion site integrity  Inquire whether passing flatus or stool Slide 28-16

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Objective Data(cont.) Objective Data (cont.)  Genitourinary  Inquire whether voiding regularly  Check urine for color, clarity  If urine output is below expected value, perform a bladder scan according to agency protocol Is problem in production of urine or its retention? Is problem in production of urine or its retention? Slide 28-17

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Objective Data(cont.) Objective Data (cont.)  Activity  Assist patient to sit up level, move to chair  Note any assistance needed, how patient tolerates movement, distance walked to chair, and patient’s ability to turn  Assess patient’s need for any ambulatory aid or equipment  Complete any standardized scales used to quantify the patient’s risk for falling Slide 28-18

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Assist Patient to Sit Up Slide 28-19

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Objective Data(cont.) Objective Data (cont.)  Electronic charting  Charting in most hospitals is at least partially computerized Although this can be intimidating at first, it has several advantages Although this can be intimidating at first, it has several advantages  First, for new clinicians, structure imposed by computerized database can serve as a prompt to guide one through a complete assessment  Second, it decreases chances that nurses will waste time waiting to gain access to paper chart or searching for it when it is not in proper location Slide 28-20

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Electronic Charting Slide From Sorrentino SA: Mosby’s textbook for long-term care nursing assistants, ed 6, St. Louis, 2011, Mosby.

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 28: Bedside Assessment of the Hospitalized Adult Objective Data(cont.) Objective Data (cont.)  Electronic charting  Charting in most hospitals is at least partially computerized (cont.) Finally, charting in a computer system is rarely dependent on writing or typing in narrative form Finally, charting in a computer system is rarely dependent on writing or typing in narrative form Check boxes and drop-down menus are much more common Check boxes and drop-down menus are much more common Slide 28-22