nursing assessment. what are we looking for? disease – -disturbance of a structure or function of...

Nursing Assessment

What are we looking for?

• Disease– -disturbance of a structure or function of the body.– -signs and symptoms.

– Signs: objective data– Symptoms: subjective data– clustered in groups

• Assessment of signs and symptoms– Assists the physician to make a medical diagnosis– Assists the nurse in making the nursing diagnosis

Etiology of Disease Etiology of Disease

hereditarycongenitalinflammatory degenerativeinfectious deficiency metabolicneoplastictraumaticenvironmentaldiseases that have no apparent cause (unknown

etiology)

Risk Factors and Development of Disease

– A “risk factor” is:• any situation, habit, environmental condition, genetic

predisposition or physiologic condition • increases the vulnerability of an individual to illness or

accident.– The presence of risk factors does not necessarily

mean that a person will develop a disease condition, only that the chances of disease are increased.

Risk Factors and Development of Disease

– Categories of risk factors • Genetic & Physiological• Age • Environment• Lifestyle

Nursing Assessment Nursing Assessment

• Initiating the Nurse-Patient Relationship– -introduce yourself – -name– -position– -purpose of the interview– -estimate of time– -opportunity for questions and answers– -communicate your trustworthiness/confidentiality.– -convey competence/professionalism.

– Purpose of the assessment:• -determine the patient’s state of health• -construct the nursing diagnosis

– Perform assessment as soon after admission as possible.• Initial assessment- Nurse and/or MD.• Ongoing assessment –LPN/RN• Nurses are often the first to detect changes in the

patient’s condition

• -relaxed, unhurried manner.• -quiet, private, well-lighted

setting.• -compassion and concern.• -what name the patient

wishes to use• -accepting posture• -relaxed• -eye level • -pleasant facial expression

The Interview

Biographical Data

– date of birth– Sex– address– family members– marital status– religious preference– occupation – source of health care– insurance

Reasons for Seeking Health Care

• Chief Complaint• - patient’s own words

• OPQRST method: – O = onset, duration of problem– P = provocation/palliation: what makes it worse or better?– Q= quality/quantity– R =region/radiation- where it is, where it goes– S = severity– T = time: when the problem started, has it been

constant

The Interview

• Past Health History– hospitalizations– allergies– specific reaction to antigen– habits and lifestyle patterns– activity of daily living’ (ADLs)– sleep, exercise, and nutrition

• Family History– Immediate/blood relatives– -health– -cause of death– -history of illness

The Interview

• Environmental History– home environment

• Psychosocial /Cultural History– -primary language– -cultural groups– -educational background– -attention span– -developmental stage– -coping skills/family support– -major beliefs, values, and behaviors

Assessment

• Subjective data• -perceived by the patient• -Pt. report; states

– Identify symptoms• nurse unaware of symptoms unless the patient describes

the sensation• description from the patient • -onset • -course• -character of the problem• -factors that aggravate/alleviate

Assessment• Objective data/signs

– -risk for illnesses– -family structure, interaction, and function– -‘barriers’ to care– -seen, heard, measured – -often verified by more than one person

• -rashes, • -altered vital signs, • -visible drainage/exudate• -Lab results, diagnostic imaging, and other studies

Physical Assessment• Review of Systems [ROS]

• Systematic method:–For collecting data on all body systems–Record in clear and concise manner–Use appropriate terminology–Ask specific questions–Assess the functioning of each system

Head to Toe Assessment

• Items needed: WASH YOUR HANDS!!• -penlight• -stethoscope• -blood pressure cuff• -thermometer• -gloves• -tongue blade• Senses of touch, smell, sight, and hearing.

• Neurologic– Level of consciousness/orientation

• -Awake and Alert? • -oriented to: • -Person (knows his name• -Place (can tell you where he is) • -Time (knows the day and date). • -Purpose (knows why you are examining him)

Head-to-Toe Assessment

• Neurologic cont.– Assess: Motor Function

• Ask pt. to move each extremity• Ask pt. to smile, frown, lift eyebrows

– Check Pupilary Response• Check for size, equality, and shape

Head-to-Toe Assessment

• Integumentary system – Observe skin – -color -scars– -temperature -lesions– -moisture, texture -wounds– -turgor -redness/irritation– -evidence of injury -color or sclera – -breaks in the skin -mucous membranes– -tongue -lips– -nail beds -palms/soles.– Hair– -quantity -quality– -distribution - smoothness– -oily/dry– Scalp should be free of dandruff, lesions, or parasites

• Assessing Skin Turgor

Grasp fold of skin on back of patient’s hand, sternum, forearm or abdomen.

• -Observe the ease and speed with which skin returns to place.

Head-to-Toe Assessment

• Strength TestingIf pain or injury begin with normal sideCompare one side to otherScore: 0 = No Active Movement

1 = Muscle contraction, no movement 2 = Full Active ROM with gravity eliminated 3 = Full Active ROM movement against gravity 4 = Full active ROM against partial resistance 5= Full active ROM overcome full resistance

Documentation Eg. -”Strength in upper extremity was 5/5”

Head-to-Toe Assessment

• Head and neck– facial expression.– symmetry of features.– arteries, veins, and lymph nodes.

• jugular vein distention– Palpate: -beneath the jaw

-side of the neck -enlarged lymph nodes

-carotid arteries. – Auscultate

- carotids for bruits.

Head-to-Toe Assessment

• Nose– -symmetrical– -patency– -bleeding/drainage.– -nares.

• Mouth and throat– -lips/mucous membranes

- use tongue blade and penlight. – -teeth/gums.– -breath odor.

• Eyes– -symmetry.– -exudate/drainage– -sclera.– -pupillary reflex– -penlight

-PERRLA (Pupils Equal, Round, Reactive to Light and Accomodation)

• Ears– -symmetry.– -ear canal.– -hear/follow commands.– -hearing aids

Head-to-Toe Assessment

• Breasts– -examine– -encourage monthly self-exams

• Spine– -curvature -sitting/standing position.

Head-to-Toe Assessment

• Pulmonary System– Chest

• -bilateral chest expansion.• -rate/rhythm of respirations.• -Breathing should be QUIET.• -posture.

Head-to-Toe Assessment

– Lung sounds• -breath through mouth quietly• -more deeply and slower • -stethoscope firmly but not tightly on the skin • -listen for one full inspiratory/expiratory cycle

at each point.• -auscultate using a zig-zag pattern.• -adventitious breath sounds = crackles,

wheezes

How does Respiration Occur?

Diaphragm

Inspiration

Inspiration

Head-to-Toe Assessment

• Cardio-vascular System–Heart sounds

• Auscultate– intensity of the sound

-faint to strong.-stethoscope

-bell picks up sounds of low frequency -diaphragm picks up sounds of high

frequency. -regularity of the rhythm.

Areas of Auscultation

Aortic Area- -second intercostal space -right of the sternum -aortic valve Pulmonary Area -second intercostal space -left of the sternum -pulmonic valve Left Lateral Sternal Border (LLSB) -fourth intercostal space -left of the sternum -tricuspid and right heart sounds Apex(Mitral) -fifth intercostal space -mitral and left heart sounds

Anatomical Heart Position

Superior Vena Cava

Aorta

Pulmonary Artery

Patient Positions for Auscultation of Heart Sounds

Sitting up, Leaning slightly

forwardSupine

Left Lateral recumbent

Heart Sounds

Lubb: -long, low-pitched sound -closure of the Tricuspid and Bicuspid Valves -Systolic Murmur Dupp: -short, sharper sound -closing of Pulmonary and Aortic Valves -Diastolic Murmur

Head-to-Toe Assessment• Peripheral vascular system

– Peripheral pulses- 8– Strength on a 0-to-4+ scale

0 = absent 1+ = thready 2+ = weak 3+ = normal 4+ = bounding

– Extremities– -symmetry– -color– -varicosities.– -temperature of hands and feet.

Capillary Refill• Time that blood refills empty capillaries

– To “empty” the capillary bed: press a fingernail or tissue bed until it turns white

– note of the time needed for color to return once the

nail is released

normal capillary refill time is less the (<) 3 seconds Capillary Refill Time (CRT) is a common measure of

peripheral perfusion.

Palpation of arterial pulses

. Popliteal

Radial Brachial Femoral

Dorsalis pedis Posterior tibial

Head-to-Toe Assessment

• Abdomen• Check for:

– Shape, lumps, contour,rashes, lesions, scars

• Auscultate:– Bowel Sounds in all quadrants

• Listen at least 1 min in each quadrant• Note hyperactive vs diminished/ absent sounds

• Palpation/Percussion

Palpation of the abdomen ----distention

-masses

- tenderness

Palpation of the liver.

Genitourinary systemSkilled observation:

labia/genitaliapubic hair.

Palpate -suprapubic area. -scrotum -encourage regular self

examination.

Rectumassess for hemorrhoids /

lesions.

Legs and Feet

– Palpate -femoral -dorsalis pedis -popliteal

-posterior tibial pulses.– Range of motion (ROM)– Color, Motion, Sensation (CMS) – Temperature

Edema

– Pitting edema 1+ “Trace” -slight pitting -no visible change in the shape of the extremity -disappears rapidly 2+ “Mild” -deeper pitting -no marked change in the shape of the extremity -disappears (“rebounds”) in 10 to 15 seconds 3+ “Moderate” -noticeably deep pitting -very edematous and distorted extremity -last from 15 seconds-1 minute 4+ “Severe” -very deep pitting -very edematous and distorted extremity -lasts as long as 2 to 5 minutesIf the edema is not pitting, it cannot be given a grade

Edema of the leg

Edema: It’s not just for legs !

Ending the Assessment

Thank the patient.Wash your handsDisinfect pen.Document your findings thoroughly.

-Documentation does impact the quality of care given.

Report any significant changes or findings to the appropriate healthcare professional.

A nurse should perform a quick assessment of each patient at the

beginning of each shift to determine actual or potential patient problems that will require medical or nursing

interventions to promote the safety and well-being of the patient.

Quick Assessment (A B Cs) A = Airway P = Pain

Includes comfort measures B = Breathing S = Safety Water and Call bell in reachC = Circulation

In = What’s going inCheck IV patencyInfusion rates, machines and tubing

Out = What’s going outDressingsChest tubesUrinary drainage tubes

http://www.youtube.com/watch?v=9Fxb8icOTOA