1. Assessments
Fundamentals Unit 7

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

3. 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

4. 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

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

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

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

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

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

10. 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!

11. 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

12. 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

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

14. 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

15. 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

16. 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

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

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

19. 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?

20. 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

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

22. 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

23. Assessments
Guidelines for assessing the…
Abdomen

24. 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

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

26. Assessments

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

28. 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