Nursing Assessment Overview

General Survey/Examination

• General Survey starts with initial interaction
• Includes observations of body structure, grooming, hygiene, facial expressions
• Assesses posture, mobility, and assistive devices
• Evaluates mood/affect, detects pain or distress
• Includes height, weight, and BMI measurements to assess nutritional status
• Examination can be head-to-toe or system-based
• Document findings accurately for baseline data comparison

Focused/Comprehensive Assessment

• Focused assessment addresses a specific issue (e.g., pain, rash). Focuses on relevant systems
• Example: Chest pain focuses on cardiovascular and respiratory systems
• Comprehensive assessment includes health history, physical examination of all systems, and psychosocial aspects
• Typically conducted during initial visits or admissions

Priority Setting

• Prioritize using Maslow's hierarchy: Physiological needs > Safety > Love/Belonging > Esteem > Self-actualization
• ABC rule: Address Airway, Breathing, and Circulation issues first
• Consider urgent vs. non-urgent conditions and severity (e.g., allergic reaction over mild pain)

Skin Assessment

• Functions: Protects against environmental damage, detects touch/pressure/pain/temperature, synthesizes vitamin D, regulates body temperature.
• Risk factors for breakdown include immobility, poor nutrition, aging, and high BMI
• Prevention includes regular repositioning, hydration, and skin care
• Pressure ulcer stages:
  • Stage I: Redness, intact skin
  • Stage II: Open wound in epidermis/dermis
  • Stage III: Damage to subcutaneous tissue
  • Stage IV: Muscle and bone exposure
• Age considerations for infants and older adults (e.g., delicate skin, slower healing in older adults)

Nail Assessment

• Functions: Protect fingers/toes, aid in picking objects, scratching
• Normal findings: Smooth, pink, firm nails with capillary refill <3 seconds
• Care: Trim nails straight across, avoid soaking hands in hot water
• Abnormalities: Clubbing (related to hypoxia), Beau lines (indicate previous illness or trauma)

Assessment Techniques

• Inspection: Systematic visual examination (general overview to specific regions) - focus on color, symmetry, shape, and movement
• Palpation (Light/Moderate/Deep): Assessing surface characteristics (1-cm depth), internal structures (1-2 cm depth), organs/masses (2-4 cm depth) - Avoiding pain or rigidity
• Percussion: Direct (assessing sinuses), Blunt (testing for pain/tenderness), and Indirect (evaluating resonance)
• Auscultation: Using the bell and diaphragm to listen to low and high-pitched sounds (murmurs, heart and lung sounds)

Primary vs. Secondary Sources of Information

• Primary: Information directly from the client (symptoms, behaviors)
• Secondary: Information from family members, medical records, or healthcare professionals

BMI Calculation

• BMI = weight (kg) / height (m)^2
• Normal range: 18.5-24.9

Therapeutic Communication

• Active listening and maintaining eye contact are crucial
• Empathy and validation of client feelings are important
• Open-ended questions help in gathering more details from the client
• Avoiding medical jargon ensures understanding

Client Interview (OLDCART Mnemonic)

• Onset (When did it start?)
• Location (Where is it?)
• Duration (How long has it been going on?)
• Characteristics (What does it feel/look like?)
• Aggravating factors (What makes it worse?)
• Relieving factors (What makes it better?)
• Treatment (Have you tried anything for it?)