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5 MINUTEASSESSMENT
Arthur Cantos RN, MANAmerican Dream Review
Institute Inc.
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WHY DO YOU NEEDTO PERFORMASSESSMENT
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Step 1: Assessment
Complete data? Lab & x-ray?
Multidisciplinary? What is going on?What are my patients Learning needs?
Step 2: Diagnosis
Potential Problems?
Top 2 Priorities?
Two Measurable Outcomes?
Step 3: Planning
What Shall I do?
Interdisciplinary?
Resources and Timeline?
Not Just Technical Care
Involve Patient and Family?Step 4: Implementation
Am I Being Effective? Efficient?
Have I Delegated Properly?
Step 5: Evaluation
Make a Difference?Modify Plan?
Accomplish Outcomes?
THE 5 STEP
NURSING PROCESS
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Your Patients for the day
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1. Mr. Puso, 52 y/o male patient of Dr. Nerva, Leftsided CHF with pulm edema, CAD and angina
2. Mrs. Asukar, 65 y/o female patient of Dr.Tormes, long-term Type I diabetic, admitted for
episode of hypoglycemia yesterday3. Mr. Baga, 70 y/o chronic COPD of Dr. Dy,
admitted for dyspnea episode 2 days ago
4. Mrs. Tiyan, 45 y/o s/p exploratory laparotomy of
Dr. Espiritu, yesterday afternoon5. Waiting for new admission from PACU Mr.
Bahag-Hari, s/p suprapubic prostatectomy ofDr. Sy.
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LIGHTSCAMERA
ACTION
Its Showtime !!!
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INTRODUCTION
1. Knock
2. Greetings
3. Introduction
Introduce self andmembers of the team
Identification and role /
function
Purpose of assessment Provide privacy
4. Plan of Care
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Perform
5. Wash hands
6. Vital Signs
Pulse Rate, Strength, Regularity
Temperature________ Oral, Rectal, Tympanic
Respiration_______________
B / P_________
Pain Assessment _________________Oxygen saturation ________________
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Head to Toe - Neuro
7. Orientation time, person, place,
reasonWhat year is this ?
________________________
Tell me your name ?
_______________________Tell me where you are ?
____________________
Tell me why you are
here?__________________
8. Pupil Check( PERRLA ) Pupils, Equal, Round, React to
light, Accommodate
Sluggish ( ) No Change ( ) Brisk ( ) Normal ( )
Accommodation Yes ( ) No ( )
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Mr. Puso
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Mr. Puso, 52 y/o male
patient of Dr. Nerva,Left sided CHF with
pulm edema, CADand anginaAmerican Dream Review
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Landmarks
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Cardiac
9. Neck VeinsPatient at 45 degree angle ( )
Neck Veins Flat ( ) Distended ( )
10.Heart TonesApical Pulse with Stethoscope
Rate ?_____________
Rhythm ? ___________Clarity of Sounds ? _________ Abnormal ? ( )
Explain ! ____________________________
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Heart TonesHeart tones are checked by
listening to the apical pulse.
This pulse is auscultated with thebell of the stethoscope.
Check the apical pulse for rate,rhythm, and clarity of thesounds of the S1 and S2otherwise known as "lub and
dub".Any abnormalities should be
reported.
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Heart SoundsHeart sounds result from the vibrations from
closure of the heart valves and theacceleration and deceleration of blood flow.
S1 - the lub sound that represents closure
of the tricuspid and mitral valves. Heardbest at the apex.
S2 - the dub sound. This represents closureof the aortic and pulmonic valves. It is theonset of ventricular diastole and is heardbest at the aortic area.
S1 split - a slight difference in valve closuretiming. This is a normal variation heard bestat the right 4th intercostals space.
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Heart Sounds S2 split - this is a splitting of the dub, or the second sound.
Heard best during inspiration at the pulmonic area. Usually
disappears in the sitting position
S3 (ventricular gallop) - normal in healthy children and
young adults and is produced by vibrations of the ventriclesdue to rapid distention. This may be seen in left ventricular
failure. Heard best at the apex with the patient lying on the
left side. Heard with the bell of the stethoscope and sounds
like Kentucky. May indicate incompetence of the mitral and
tricuspid valves.
S1 S2 S3 Ken tuck ee Lub dub dub
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Heart Sounds
S4 (atrial gallop or presystolic gallop) - Heard best over the
apex with the pt in lying supine.
Indicative of increased resistance to filling and may be associated
with coronary artery disease, hypertension, aortic stenosis, or
the elderly.
This sound is heard best with the bell of the stethoscope over the
left lower sternal border. It sounds like Tennessee.
S4 S1 S2 Ten ne see Dub lub dub
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Heart SoundsClassifications
Diastolic Murmurs - occurbetween S2 and S1. Seenin mitral or tricuspid
stenosis, aortic or pulmonicinsufficiency.
Systolic murmurs - occurbetween S1 and S2. Seenin aortic or pulmonic
stenosis or mitral ortricuspid insufficiency. Theyare also called holosystolicor parasystolic murmurs.
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Heart SoundsHeart Murmurs - are caused by
increased flow through normalstructures.
Areas for AuscultationMitral murmurs are heard best with the
patient in the left lateral position.
Aortic murmurs are heard best withthe patient sitting and leaning forward
after complete exhalation.
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Cardiac
11. Bilateral Checks
( Radial Pulses ) - Rate, Strength, Regularity
Right_____________ Left______________
( Hand Strength ) - 2 fingers onlyRight Stronger ( ) Left Stronger ( ) Equal ( )
( Pedal Pulses DP/PT ) - Top of Foot
Right Foot __________ Left Foot ____________
( Capillary Refill ) - On fingers or toes 3 seconds or lessRight Fingers ( ) sec. Left Fingers ( ) sec.
Right Toes ( ) sec. Left Toes ( ) sec.
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Mr. Baga
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Mr. Baga, 70 y/o
chronic COPD of Dr.Dy, admitted for
dyspnea episode 2days ago
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Landmarks
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Pulmonary Assessment
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Pulmonary
12. Breath Sounds
Assess anterior and posterior and from side to side, left
to right lobe.
Have patient take deep breaths, do not movestethoscope to rapidly to avoid hyperventilating on
patients part.
Clear Bilaterally ( ) Left only ( ) Right only ( )
diminished, tight bilaterally ( )
Crackles or Rales, Fine or Coarse Crackles, Rhonchi
Good air flow ( ) Poor air flow ( )
ICSP __________
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Breath SoundsThe diaphragm of the stethoscope is
used for assessing breath sounds.
The right middle lobe is assessed bylistening on the patient's rightside.
Have the patient take deep breaths inand out of their mouth.
Nose breathing can create airturbulence that may alter thesounds.
Breath sounds should be clearbilaterally with good air flow.
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Breath SoundsNormal breath sounds
Bronchial sounds - Pitch: High. Intensity: Loud,predominantly on expiration. Normal findings: A soundlike air blown through a hollow tube
Bronchovesicular sounds - Pitch: Moderate.Intensity: Moderate. Normal findings: A blowing soundheard over airways on either side of sternum, at angleof Louis, and between scapulae
Vesicular sounds - Pitch: High on inspiration, low onexpiration. Intensity: Loud on inspiration, soft toabsent on expiration. Normal findings: Quiet, rustlingsounds, heard over periphery
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Breath SoundsAbnormal breath sounds - diminished, distant or tight
Bronchial sounds - Pitch: High. Intensity: Loud, predominantlyon expiration. Normal findings: A sound like air blown through ahollow tube
Bronchovesicular sounds - Pitch: Moderate. Intensity:
Moderate. Normal findings: A blowing sound heard over airwayson either side of sternum, at angle of Louis, and betweenscapulae
Vesicular sounds - Pitch: High on inspiration, low on expiration.Intensity: Loud on inspiration, soft to absent on expiration.
Normal findings: Quiet, rustling sounds, heard over periphery
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Breath SoundsADVENTITIOUS SOUNDS Crackles (Rales)
Where to auscultate: Over lung fields and airways; heard inlung bases first with pulmonary edemaTiming:More obvious during inspiration
Cause: Moisture, especially in small airways and alveoliDescription: Light crackling, bubbling; nonmusical
Rhonchi (Gurgles) and Coarse CracklesWhere to auscultate: Over larger airways
Timing: More pronounced during expirationCause: Airways narrowed by bronchospasm or secretionsDescription: Coarse rattling, usually louder and lower-pitched than crackles; described as sonorous, musical.Rhonchi typically clears with coughing.
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Breath Sounds Wheezes
Where to auscultate: Over lung fields and airwaysTiming: Inspiration or expirationCause: Airways narrowed by bronchospasmDescription: described as sonorous, musical, or sibilantCreaking, Whistling; high-pitched, musical squeaks
Pleural Friction RubWhere to auscultate: Front and side of the lung field
Timing: InspirationCause: Inflamed parietal and visceral pleural surfacesrubbing together.Description: Grating or squeaking
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Neck VeinsNeck veins should be checked by
having the patient sit at a 45
degree angle. In this position,
the jugular veins should be
flat.Distended neck veins at 45
degrees are an indicator of
over hydration or fluid
overload.
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Mrs. Tiyan
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Mrs. Tiyan, 45 y/o s/p
exploratory laparotomy ofDr. Espiritu, yesterday
afternoon
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Gastro-intestinal
13. Bowel Sounds Assess all 4 quadrants, do not touch stomach before
auscultation, as it may disrupt normal sounds. If
irregular,
1 minute assessment on each quadrant. Umbilicus ismid point.
( Stomach ) - Check for condition
Soft ( ) Hard ( ) Distended ( ) Other
RUQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( ) RLQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )
LUQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )
LLQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )
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Mr. Bahag-Hari
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Waiting for new admissionfrom PACU Mr.Bahag-Hari, s/p
suprapubic
prostatectomy of Dr. Sy.American Dream Review
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Genito-Urinary
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Genito-urinary
14. Ask the patientUrgency, Burning, Incontinence, pain
15.AssessCatheter, Drainage, Urine output
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Mrs. Asukar
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Mrs. Asukar, 65 y/o femalepatient of Dr. Tormes,
long-term Type Idiabetic, admitted for
episode of hypoglycemiayesterday
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Integumentary
16. Skin Skin Turgor - 1 to 3 second return, on Sternum
Return was ( ) sec. Abnormal ( ) sec.
Skin Color - Check on inside of Lip or Conjunctiva
Lip ( ) Conjunctiva ( )Pink ( ) Pale ( ) Jaundice ( ) Cyanotic ( )
Skin Temperature - Use back of hand to check
Hot ( ) Warm ( ) Cool ( )
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Braden Scale
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17. Skin Breakdown Check
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Peripheral EdemaEdema, or fluid in the tissues tends
to go to dependent areas of the
body. This may be the hands,
feet or sacrum.
For the bed rest patient, thedependent area is most often
the sacrum.
To check for edema push your
finger down on the feet, hands,and sacrum. Observe for
indentation or pitting.
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ASSESSMENT SCALE FOR
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ASSESSMENT SCALE FOR
PITTING EDEMA
1+ slight pitting, no visible distortion, disappears
rapidly
2+ somewhat deeper pit than 1+, no readily detectable
distortion, disappears in 10-15 sec.3+ pit noticeably deep, may last more than a minute;
the dependent extremity looks fuller and swollen.
4+ pit very deep, lasts 2-5 min; dependent extremity is
grossly distorted.
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Vascular
18.Peripheral Edema
Edema is found in dependent areas such as the feet,
hands, sacrum. Check with finger by pressing down.
Observe for pitting or indentation.Feet Yes ( ) No ( ) Pitting ( ) R ( ) L ( )
Hands Yes ( ) No ( ) Pitting ( ) R ( ) L ( )
Sacrum Yes ( ) No ( ) Pitting ( ) Indent
19. Distal Pulses Dorsalis Pedi and Post Tibial
Palpable or dopplerable
Arterial or venous
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Post Tibial
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Dorsalis Pedis
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Vascular
20.Homan's SignAsk patient to dorsiflex both feet.
Pain in right calf Yes ( ) No ( )
Pain in both calves Yes ( ) No ( )
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Pain Assessent
21. Assessing For Pain (PQRST method)
P Provokes, palliative measure
Q Quality (describe)
R Region, radiate?S Severity, on a scale of 0 - 10
T timing, when did it start? How long does it last?
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Psychosocial
22. Psychosocial Aspects
Affect of illness on role such as work, family
Inappropriate independence, dependence?
Check for depression, suicidal ideation if
needed.
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Education Assessment
23.Response to learning
Learning barriers
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Closure
24. Closure
Let the patient know you are finished and
when you will be back.
Bedrails up ( )
Bed in low position ( )
Call light in reach ( )
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QandA
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ITS
SHOWTIME!
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