Podcast
Questions and Answers
Initial observations of a patient's hygiene, posture, and facial expressions are part of what type of assessment?
Initial observations of a patient's hygiene, posture, and facial expressions are part of what type of assessment?
When prioritizing patient care, which of the following should be addressed first, according to Maslow's Hierarchy?
When prioritizing patient care, which of the following should be addressed first, according to Maslow's Hierarchy?
A patient presents with a localized rash on their forearm. What type of assessment would be most appropriate?
A patient presents with a localized rash on their forearm. What type of assessment would be most appropriate?
Which of the following does the skin NOT do?
Which of the following does the skin NOT do?
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A pressure ulcer with damage to the subcutaneous tissue is classified as what stage?
A pressure ulcer with damage to the subcutaneous tissue is classified as what stage?
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What is a common risk factor for skin breakdown?
What is a common risk factor for skin breakdown?
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Which of the following is a normal finding when assessing the nails?
Which of the following is a normal finding when assessing the nails?
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An assessment that includes health history, physical examination of all systems, and psychosocial aspects is what type of assessment?
An assessment that includes health history, physical examination of all systems, and psychosocial aspects is what type of assessment?
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Study Notes
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?)
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Description
Explore the key concepts of nursing assessments, including general surveys and focused examinations. Learn how to accurately document findings and prioritize patient care based on Maslow's hierarchy and the ABC rule. This quiz will enhance your understanding of comprehensive and focused health evaluations.
