Nurse's Role in Health Assessment & Bedmaking PDF

Nurse’s Role in Health Assessment & Bedmaking Module Two  Discuss how to make an occupied & unoccupied bed. Describe the role of the professional nurse in health assessment Demonstrate knowledge and the purposes of health assessment Objectives Describe com...

Nurse’s Role in Health Assessment & Bedmaking Module Two  Discuss how to make an occupied & unoccupied bed. Describe the role of the professional nurse in health assessment Demonstrate knowledge and the purposes of health assessment Objectives Describe components of a General Survey Demonstrate knowledge of the differences in the types and frequencies of assessments. Discuss frameworks for collecting health assessment data Learning Objectives Explain the purposes of physical assessment & a General Survey. Describe cultural diversity, cultural competency, and cultural safety as these relate to the provision of culturally competent health and physical assessment and improved patient health outcomes. Identify data to collect from the nursing history before a physical examination. Describe environmental preparations necessary prior to a physical examination. List techniques used to prepare a patient physically and psychologically before and during an examination. Check-In & Reminders IN-PERSON LAB CLS LAB QUIZ 1 CLS LAB QUIZ 2 EXPERIENCE Bed Making Module Two  When changing bed linen, nurses need to follow the principles of medical asepsis by keeping soiled linen away from their uniform. Soiled linen is placed in special linen bags before discarding it in a hamper. BED To avoid air currents, which can spread microorganisms, bed linens should never be shaken. MAKING To avoid transmitting infection, soiled linen should not be placed on the floor. If clean linen touches the floor, it should be immediately discarded (Perry & Potter, 2019) Terms you should know: Fowler’s HOB elevated at least 45 degrees Semi-fowler’s HOB elevated at 30 degrees Trendelenburg Entire frame tilted, HOB down Reverse Entire frame tilted, FOB down trendelenburg Flat Bed & frame horizontal and parallel to floor Table 38-6 Fundamentals  A patient's bed should be kept clean and comfortable This requires frequent inspections to be sure linen is clean, dry, and free of wrinkles. Why would we want to make sure a patient's bed was free of wrinkles? BED MAKING When patients are diaphoretic, have draining wounds, or are incontinent, nurses should check frequently for soiled linen (Perry & Potter, 2019)  The bed is usually made in the morning after the patient's bath or while the patient is in the shower, sitting in a chair eating, or out of the room for procedures or tests Throughout the day, bed linens should be straightened when they become loose or wrinkled. BED The bed linen should also be checked for food particles after meals and MAKING for wetness or soiling. Linens that are soiled or wet should be changed. (Perry & Potter, 2019)  During bed making, it is important to use proper body mechanics. More than half of all back pain in health care settings is associated with manual lifting tasks (Work Health & Safety Centre, 2019). Back injuries most often direct result of improper lifting and bending BED The bed should always be raised to the appropriate height before changing linen so that you do not have to bend or stretch over the mattress. MAKING You should also move back and forth to opposite sides of the bed while putting on new linen. Body mechanics is also important when turning or repositioning the patient in bed (Perry & Potter, 2024)  Procedure for Making an Occupied Bed Equipment Prepare Bed Comfort Asepsis Prepare Cover Dispose assemble hand hygiene body mechanics - client comfort - apply gloves for loosen top linens cover client with all linens that are equipment adjust height of offer bedpan and bedpan removal, and determine suitable sheet or removed, kept bed to waist level. provide privacy and removal of what is clean or blanket away from your Why? bed linens dirty, remove to uniform, and are hamper or client gently placed into bedside table a laundry hamper (Potter & Perry, 2019)  Procedure for Making an Occupied Bed cont’d Slide up Position Be Make Roll Make Ask Side With bed flat if Position client Gloves can be Make ½ of bed: Roll client back Make other ½ of Ask client if they Side rails up, call possible, slide facing far side of removed at this tuck dirty linen over to other side bed applying toe are comfortable bell in place client up mattress bed: side rail up & time under patient & towards you: raise pleat, bed cradle, into proper adjust the pillow apply clean linen side rails & adjust pillowcase etc position and ensure to near side of bed the pillow comfort using fan fold technique (Potter & Perry, 2019) Procedure for Making an Unoccupied Bed An unoccupied bed can be open or closed. In an open bed, the top covers are folded back so that a patient can easily get into bed. In a closed bed, the top sheet, blanket, and bedspread are drawn up to the head of the mattress and under the pillows. A closed bed is prepared in a hospital room before a new patient is admitted to that room. A surgical, recovery, or postoperative bed is a modified version of the open bed. The top bed linen is arranged for easy transfer of the patient from a stretcher to the bed. The top sheets and bedspread are not tucked or mitred at the corners. Instead, the top sheets are folded to one side or to the bottom third of the bed. This makes it easier to transfer the patient into the bed. (Perry & Potter, 2019)  General Survey General health state & any obvious physical characteristics. Should give an overall impression. Begins at the moment you first encounter the patient. Includes these four areas: Physical appearance Body Structure Mobility Behaviour (Jarvis, 2019) Nurse's Role in Health Assessment  Clean the equipment Clean vs. used area for handling equipment Nosocomial infections A Safer Handwashing or alcohol-based hand rub Environment Wear gloves Standard precautions Transmission-based precautions (Perry & Potter, 2019)  Inspection Palpation Assessment Techniques Percussion Auscultation  Inspection (sight and smell) –ALWAYS do first –Do not rush – look carefully –Compare patient’s right side with left side Cultivating –Use good lighting Your Senses –Will include instruments in many body systems Otoscope/ophthalmoscope Penlight (Jarvis, 2019)  Concentrated watching, close/careful scrutiny Compare patient’s right and left sides Inspection (symmetrical) Use good lighting Ensure adequate patient exposure Ensure adequate patient exposure Will include instruments for specific body systems: Otoscope Ophthalmoscope Specula: vaginal, nasal Penlight Which of the following falls under inspection? 1 2 3 4 1.Assessing 2.Determining 3.Smelling 4.Checking skin warmth liver size wound reflexes drainage  Using sense of touch can confirm points noted during inspection Slow and systematic Light versus deep palpation Palpation Intermittent pressure Bimanual palpation (Jarvis, 2019)  Use specific parts of the hand: Fingertips—best for fine tactile discrimination, for example, of skin texture, swelling, pulsation, and determining presence of lumps A grasping action of the fingers and thumb—to detect the Palpation position, shape, and consistency of an organ or mass Techniques The dorsa (backs) of hands and fingers—best for determining temperature because the skin is thinner here than on the palms Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand— best for detecting vibration (Jarvis, 2019)  Percussion Tapping skin with short, sharp strokes to assess underlying structures Yields palpable vibration and characteristic sounds: Location, size, density of underlying organ Direct percussion: * Striking hand contacts body wall directly Indirect percussion: Stationary hand, Striking hand (Jarvis, 2019)  Resonance Hyperresonance Percussion Tympany Sounds Dullness Flat Jarvis, 2019  Technique and Procedure Use sense of hearing for detecting sounds produced by heart, blood vessels, lungs, and abdomen, channeled through a stethoscope Fit and quality of stethoscope: Diaphragm and bell endpieces Auscultation Eliminate confusing artifacts Learning begins with comfort in identifying normal sounds (vs. abnormal and extra sounds) (Jarvis, 2019) Our Bodies Are Noisy! VOLUNTARY – SIGH INVOLUNTARY – HEART LISTEN FOR: Intensity, DIRECT – EAR INDIRECT – DEVICE LIKE SOUNDS Pitch, Duration, Quality, A STETHOSCOPE Location  Diaphragm for high pitched sounds - e.g. breath, bowel & normal heart sounds Bell for low pitched sounds – e.g. heart sounds, murmurs, hard to hear BP Need a perfect seal with bell as environmental noise will Using the distort the sound perceived Stethoscope Eliminate artefact sounds– may wet hairy areas to minimize friction (Jarvis, 2019) To promote clear & accurate communication anatomical Anatomical position has been adopted internationally to Used to describe client’s body structures, surfaces, or Terms functions standardize descriptions of assessment findings (Jarvis, 2019)  Anatomical Planes Sagittal – any vertical plane parallel to median Coronal – divides body in half at 900 to the median Anatomical Planes Horizontal or Transverse- divides body horizontally in half at umbilicus Median – divides body vertically in half (Jarvis, 2019) Anatomical Surfaces & Terms of Comparison Used to describe locations in relation to other body structures Examiners avoid using the terms “on”, “over”, “above”, “under”, etc (Jarvis, 2019) Anatomical Planes of Movement Range of Motion Movement occurs (ROM) is described at the articulation with respect to the of bones anatomical planes Introduction A holistic assessment includes information about the emotional, intellectual, physical, psychosocial, spiritual, and cultural dimensions. A complete health assessment involves: A nursing history Behavioural and physical examination A cultural assessment (Elseiver, 2024) Social and Cultural Considerations A holistic assessment includes information about the emotional, intellectual, physical, psychosocial, spiritual, and cultural dimensions. A complete health assessment involves: A nursing history Behavioural and physical examination A cultural assessment (Elsevier, 2024) Purposes of Physical Examination To gather baseline data To supplement, confirm, or refute data obtained in the history To confirm and identify nursing diagnoses To make clinical judgements about the patient’s changing health status, management To evaluate the outcomes of care (Elsevier, 2024) Gathering a Health History The collection of health history and physical examination data requires patience and a dedication to comprehensiveness and detail. Conducting a successful interview is based on several principles, relational practice being foremost. Orient the interview to the patient, not to a disease. (Elsevier, 2024) Developing Nursing diagnoses and a Care Plan The nurse must think critically about the information the patient provides, apply knowledge from previous clinical care, and methodically conduct the examination to create a clear picture of the patient’s health status. A complete assessment is necessary to form a definitive nursing or medical diagnosis. Each abnormal finding will prompt the collection of additional information. (Elsevier, 2024) Managing Patient Problems When caring for patients, the nurse assesses and performs a variety of interventions. The nurse’s success in giving care depends on the ability to recognize a change in status and to modify interventions so that patients achieve the most desirable outcomes. (Elsevier, 2024) Types of Assessments EMERGENT INITIAL FOCUSED COMPREHENSIVE ASSESSMENT ASSESSMENT HEALTH HISTORY (Jarvis, 2019) Evaluating Nursing Care Nurses demonstrate accountability for their nursing care through evaluating the results of nursing interventions. Nurses use physical assessment skills to assess a condition and evaluate a patient’s response to care. (Elsevier, 2024)  As defined by the World Health Organization is " the process of enabling people to increase control over , and to improve their health". Health Promotion Five Principles: Involves the population as a whole in the context of their everyday lives. Directed toward action on the social determinants of Moves from a focus on health individual behaviour towards a Combines diverse but complementary methods. Seeks to achieve effective and concrete public wider range of social and participation environmental interventions. Nurtured and enabled by health care providers, particularly those in primary care (Jarvis, 2019) (Jarvis, 2019)  Types of Data Primary Sources Information gathered from the client, interview, narrative Secondary Sources Client Chart Nursing notes, prescriber notes, diagnostic reports, laboratory data etc Tertiary Sources Relevant literature Nurses experience (Perry & Potter, 2019)  Summary Baseline assessment findings reflect the patient’s functional abilities & serve as the basis for comparison with subsequent assessment findings. Inspection requires good lighting, full exposure of the body part, & a careful comparison of the part with its counterpart on the opposite side of the body. Palpation involves the use of parts of the hand to detect different types of physical characteristics. Auscultation is used to assess the character of sounds created in various body organs. Information from the history helps to focus on body systems likely to be affected. The nursing process employs critical thinking to identify, diagnose, and treat patients’ responses to health and illness. Nursing assessment involves the collection & verification of data & the analysis of all data to establish a database about a patient’s perceived needs, health problems, and responses to those problems. To conduct a comprehensive assessment, nurses use a structured database format or a problem-oriented approach. To form a nursing judgement, nurses critically assess a patient, validate the data, interpret the information gathered, and look for diagnostic cues that will lead them to identify the patient’s problems. Caregivers and friends sometimes offer observations about the patient’s needs; these observations will affect the way the nurse delivers care. (Elsevier, 2024) For Lab this week Full uniform (scrubs, running shoes, Mohawk ID, pencil/paper, fine tip dry erase marker) Remember to regularly check your announcements Your lab group is posted under the ”people” tab in MyCanvas Attendance is taken every week for inperson lab. This is part of weekly lab engagement marks If you are going to be absent at any time during the semester, please email your professor & instructor to advise. Expectation is that student attend in person lab having read the weekly content.  References Jarvis, C. (2008). Physical examination & health assessment, 5th ed. St. Louis, Mi : Saunders Elsevier. Potter, P., Perry, A. G., Stockert, P., Hall, A. (2019). Canadian fundamentals of nursing (6th ed,. Astle, B. J., & Duggleby, W. Eds.). Elsevier Canada. Potter, P., Perry, A. G., Stockert, P., Hall, A. (2019). Canadian fundamentals of nursing (6th ed,. Astle, B. J., & Duggleby, W. Eds.). Elsevier Canada. Potter, P., Perry, A. G., Stockert, P., Hall, A. (2024). Canadian fundamentals of nursing (7th ed,. Astle, B. J., & Duggleby, W. Eds.). Elsevier Canada.