Assessment Basics PDF

Assessment Basics Dr Alhassan Sibdow Basics= Assessment techniques 1.Inspection 2.Palpation 3.Percussion 4.Auscultation Applications Conduct assessment of all body systems = ABC 1. Respiratory system = breath sounds 2. Cardiac assessment = Heart sounds 3. Renal assessment and Labs 4....

Assessment Basics Dr Alhassan Sibdow Basics= Assessment techniques 1.Inspection 2.Palpation 3.Percussion 4.Auscultation Applications Conduct assessment of all body systems = ABC 1. Respiratory system = breath sounds 2. Cardiac assessment = Heart sounds 3. Renal assessment and Labs 4. Abdominal assessment 5. CNS assessment Auscultation points Bell part= metal hollow portion = use to listen low pitch sound = blood vessels Diaphragm = flat surface= use to listern to high pitch sound= heart lungs, abd. 1. Aortic point = 2nd intercostal space, right sternal border 2. Pulmonic point = 2nd intercostal space, left sternal border 3. Tricuspid point = 4th intercostal space, left lower sternal border 4. Mitral/apex point = 5th intercostal space, mid Other cardiac assessment data 1. Cyanosis, pallor = low cardiac output, hypoperfusion, obstruction 2. Edema in upper extremities = obstruction in the lymph drainage 3. Edema in lower extremities = occlusion of veins, lymphatic obstruction, heart failure (R-side/ Cor- pulmonale) 4. Calf pain (Homan sign/ claudication)= Deep Vein Thrombosis 5. Low Hb, RBC, with unaffected weight in pregnancy= Malnutrition Renal assessment 1. Discharges or swelling of the external genitals 2. Retractions foreskin (prepuce) in males = phimosis, paraphimosis 3. Assess for tastes= oval in shape two present, 4. Urine = pale yellow as normal = dark yellow, coffee urine, blood, dribbling, urgency, frequency, cells 5. Flank pain = pyelonephritis= E.coli Abdominal assessment 1. Use inspection, auscultation, percussion, palpation 2. Palpation and percussion stimulate peristalsis and pain 3. Inspection = colour, distension, varicose; caput medusa, spider angioma= liver cirrhosis= portal HPT, ascites 4. auscultation= bowel sound; start from the RLQ=normal sound; borborygmus= increase peristalsis (metabolic alkalosis) 5. Percussion: tympany in four quadrants, liver/ spleen expect dullness, 6. Palpation: enlarged, nodular, tender, hard mass (liver dx= cirrhosis), palpable speen (mononucleosis), palpable kidneys (Wilms tumor, hydronephrosis) Neurological assessment CNS= PERFORMS MOTOR AND SENSORY = MOVEMENT, SENSATION, COMMUNICATION, COORDIANTION, COGNITION 1. TWO MAIN NERVES = CRANIAL AND SPINAL NERVES 2. CRANIAL = 12 TYPES 3. SPINAL NERVES = 31 TYPES 4. PERIORITY IS THE CRANIAL NERVES 12 CRANIAL NERVES AND THEIR FUNCTIONS NEURO ASSESSMENT 1. OLFACTORY = PATENCY OF NOSE, SUE SUBSTANCE PATIENT CAN SMELL 2. OPTIC NERVE = SNELLENS CHART TEST FOR VISUAL ACUITY, VISUAL FILED, OHPTHALMOSCOPE 3. EXTRAOCULAR EYE MOVEMENT = OCULOMOTOR, TROCHLEAR, ABDUCENS = PUPIL RXN, EYE MOVEMENT, NYSTAGMUS (BACK/FORTH EYE OSCILLATION), PTOSIS, STRABISMUS, 4. TRIGEMINAL NERVE: PARAXYSMAL PAIN (Trigeminal neuroglia), mastication (chewing), NEURO ASSESSMENT 1. Facial nerve = facial expression; paralysis = facial palsy, check tastes 2. Acoustic nerve = hearing 3. Glossopharyngeal + Vagus = gag reflex = apply to NG tube 4. Spinal accessory= control shoulder and neck movement = check drop shoulder, pain 5. Hypoglossal = tongue movement for commutation and sound 6. Glasgow Coma Scale Glasgow Coma Scale 1. Three components of GCS = eye opening, verbal response, motor response 2. Eye-opening = score = 4 3. Verbal response = score = 5 4. Motor response= score = 6 5. Total GCS = 4+5+6=15 = fully alert, intact neuro fxn. 6. Lowest score = 3= coma= unconscious 7. Score 4-7= semi-conscious 8. At least 8 = conscious 9. Lovette scale assesses the functional ability of a patient and strength PRIORITISATION Dr Alhassan Sibdow Priority 1. Plan of care that takes precedence over other nursing actions= most important action= most appropriate action/intervention/implementation; highest or lowest priority 2. Life-threatening situations take the highest priority; use the Airway (A), Breathing (B), Circulation (C) rule 3. Maslow’s needs theory: physiological needs = oxygen (breathing), fluids, nutrition, body temp., elimination, rest & sleep, sex (coitus), safety, psychological, love & belonging, self-esteem(worth, value, identity, respect, image), actualise (learn, independent, creative, aesthestic or beauty, spiritual fulfilment) Priority setting rules cont. 1. Consider what is important to the patient 2. Actual health problem before risk/ potential health problem 3. Unstable clients (12- 24 hours) 4. Consider the amount of time, material, equipment, 5. Attend to patient first before equipment; patient first before IV lines, catheter, drainage 6. Interventions must be based on the type of action; independent, dependent, collaborative Types of Nursing interventions 1. Independent= initiated by nurse based on the licence; knowledge, skills, competence 2. Dependent= action or intervention is based on a physician order, ward protocol/ clinical guidelines, routines 3. Collaborative = health team actions (nurse, doctor, dietician, pharmacist) Delegation of action 1. Any action that take priority cannot delegate 2. Any invasive procedure cannot be delegated 3. Any assess detailed assessment cannot be delegated (except vitals of stable patient) 4. Patient teaching/education cannot be delegated 5. Blood transfusion cannot be delegated 6. Total Parenteral Nutrition (TPN) cannot be delegated Sample application questions You have been assigned to monitor a patient who has a shock lungs and currently on a ventilator. You observed that the patient carbon dioxide reads 63 mmHg. What will be your MOST appropriate action? A. Continue to monitor ABG values B. Inform the in-charge the patient is not ready for weaning C. Disconnect the ventilator and ventilate while you call a respiratory therapist. Sample question A male client in your neighborhood confided in you about the challenges of his two wives giving birth. He acknowledges how worried he is about his current condition as he has tried all interventions to no avail. What will be your most appropriate action? A. Provide pre-conception counseling B. Refer them to a reproductive clinic for invitro fertilization C. Give them labs and recommend some drugs for Sample question Kofi, a 50-year-old male, has been diagnosed with rheumatoid arthritis. The nurse is caring for this patient will institute which appropriate nursing intervention first for this patient? A. Assisting the patient with gluten-free meal planning B. Teaching the patient stress management techniques C. Administering prescribed disease-modifying Sample question Miriam, a 55-year-old patient, has been diagnosed with celiac disease and admitted to the hospital. The nursing team is actively involved in providing care to manage her condition effectively. Which nursing intervention is essential in the treatment of celiac disease? A. Monitoring blood pressure regularly B. Assisting with gluten-free meal planning C. Administering pain medications for abdominal Sample question Maame, a 55-year-old female, has been diagnosed with systemic sclerosis. The nurse is providing patient education to prevent complications associated with the condition. What nursing intervention is MOST appropriate for this patient? A. Assisting the patient with relaxation techniques B. Applying cold compresses to affected areas C. Providing education on skin protection and THANK YOU FOR THE OPPORTUNITY BEST WISHES