1. Basic Head to toe assessment number 5 Including: Abdominal assessment: Auscultation and palpation Musculo-skeleto recap, Swelling and deformity, Skin Assessment

2. The nurse says: “We’re just going to look at the patient’s belly.” What questions does she ask the patient? “Any nausea or vomiting?” No. “When was your last bowel movement?” Last night.

3. “Can you describe it to me?” Brown, pretty firm and easy. “So you are not constipated?” No How often do you have a bowel movement? Twice a day.

4. Assessing the abdomen Which point indicates the centre of the abdomen for the purposes of examining the abdomen? The umbilical is the centre and the abdomen is divided into 4 quadrants.

5. What should the nurse observe when assessing the abdomen? Does it look round? Does it look flat? Are there any scars or piercings?

6. The nurse asks: “So, you haven’t had any abdominal surgery?” ( you can also say: Have you had any abdominal surgery?) “Are you having any abdominal pain?” (you can also say: Do you have any abdominal pain?)

7. Auscultation The nurse says: “I’m just going to listen in each quadrant.” She can hear gurgling. (to gurgle = “gorgogliare”) Nurse: Have you had your breakfast? Patient: No. He has very good bowel tones. How many bowel sounds per minute are normal? 5 to 35 (five to thirty-five) sounds per minute Are bowel tones present in all 4 quadrants? Yes they are.

8. Palpation What should the palpation be like? Hard,Gentle, Strong ? Palpation should be gentle in assessing for pain. What should the nurse look at when palpating the abdomen? The nurse should look at the patient’s face for any signs of pain. What position should the nurse’s hand be in for palpation? “Use the flat of the hand”

9. The nurse asks: “How is your urination?” Any burning? Frequency? Are you able to empty your bladder? So, When you go you don’t feel like you have anything left in there? No blood in your urine?

10. Musculo-skeleto What does CMS stand for? Circulation Motion Sensation Circulation was already checked for when we checked the patient’s pulses and cap refill, skin colour and temperature. (In a previous video) Motion or Motor: was checked in the muscle strength test where Jessie had 5/5 on all extremities. (In a previous video)

11. Plantar- and dorsiflexion

12. Plantar flexion The patient must push down on the nurse’s hands with his feet, pointing toes down. You should ask yourself: Is it strong and equal? Dorsiflexion “Have the patient flex his feet the other way (up), against your hands”. Again- there is no scale, you just check for Strength and equality

13. Sensation: “Are you having any numbness or tingling?” Numbness = “insensibilità, intorpidimento” Tingling = to tingle = “formicolare, pizzicare” Nurse: “Tell me where I am touching you.” Patient: “The outside of my right foot”, “The inside of my left foot”. “ My pinky toe”, “third toe” Are you having any pain? (Are you in any pain?)

14. Swelling and deformity If you have a patient with one leg (or arm) more swollen than the other, you need to keep a check on it. (= monitor any increase in swelling). (Nurse Brenda’s advice: “Keep a tape measure in your pocket, but wipe it off between patients.”) Why does the nurse mark the patient’s leg with a black marker? So that the patient’s leg is always measured in the same place while monitored. How much does Jessie’s calf measure? 36.5cm (thirty six and a half centimetres). Always chart the measurements and mark both extremities (both arms or both legs)

15. Skin scaly skin Eczema Pale patches

16. Assess the patient’s skin as you work down the body during the assessment. Does Jessie suffer from any skin conditions? Yes, he has some eczema and patchy marks. Does he use any medication for his skin problem? Just some lotion. How does the nurse describe Jessie’s skin overall? His skin is intact, pink, warm and dry.