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Assessment. WOJAK TOOL BOX Words Words Observation Observation Judgment Judgment Action Action Knowledge Knowledge.

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Presentation on theme: "Assessment. WOJAK TOOL BOX Words Words Observation Observation Judgment Judgment Action Action Knowledge Knowledge."— Presentation transcript:

1 Assessment

2 WOJAK TOOL BOX Words Words Observation Observation Judgment Judgment Action Action Knowledge Knowledge

3 WORDS Words are important: Words are important: Agnosia – no sensory recognition of common objects of common objects Apraxia – can not perform skilled motor acts Aphasia – communicate problem receptive and/or expressive receptive and/or expressive

4 Observation Observe – ABCS: Affect Affect Behavior Behavior Cognition Cognition Signs Signs

5 Judgment Act Act or or Don’t act Don’t act

6 Action Fix it Fix it or or Call Call

7 Knowledge Basic Knowledge – e.g. lab values Basic Knowledge – e.g. lab values “Life Long Learning” – stay current “Life Long Learning” – stay current Continuous acquisition – e.g. technology Continuous acquisition – e.g. technology Read Read Write Write Evaluate – cite your source! Evaluate – cite your source!

8 Think Logically Gather Data OLD CARTS Onset Onset Location Location Duration Duration Character Character Aggravates Aggravates Relieves Relieves Treatment Treatment Scales Scales

9 OLD O nset – min, hrs, days, weeks, months, years O nset – min, hrs, days, weeks, months, years L ocation – ask the one finger focusing question L ocation – ask the one finger focusing question D uration – constant, intermittent D uration – constant, intermittent

10 CARTS

11 Character A ching A ching Throbbing Throbbing Crushing Crushing Burning Burning Shocking Shocking Tingling Tingling Sharp Sharp Dull Dull etc. etc.

12 Aggravates Movement Movement Coughing Coughing Meds Meds Turning Turning Light Light Noise Noise Breathing Breathing Swallowing Swallowing Etc. Etc.

13 Relief Movement Movement Heat Heat Cold Cold Rubbing Rubbing Meds Meds Distraction Distraction Ask about: Ask about: Street Drugs, ETOH, OTCs, OPDs Street Drugs, ETOH, OTCs, OPDs etc. etc.

14 Treatments None None Medication Medication Physical Therapy Physical Therapy Surgery Surgery Ask: Did it help ? Ask: Did it help ?

15 Scales Pain: 0 no pain, 10 is the worse pain you could imagine, use pictures or gestures. Pain: 0 no pain, 10 is the worse pain you could imagine, use pictures or gestures. REMEMBER: RPM 225 Normal REMEMBER: RPM 225 Normal Reflex Reflex Pulse Pulse Muscle Muscle Pupils Pupils

16 Think Logically Collect Data OLD CARTS

17 Action Vital Signs –Pulse: rate & rhythm, amplitude Vital Signs –Pulse: rate & rhythm, amplitude Respiratory: rate, rhythm, depth Respiratory: rate, rhythm, depth Blood Pressure: pulse pressure, orthostatic Blood Pressure: pulse pressure, orthostatic Temperature: oral Temperature: oral Perform – auscultate, palpate, percuss Perform – auscultate, palpate, percuss hear, touch, tap hear, touch, tap (when appropriate !) (when appropriate !) Document – What the client tells you “…” Document – What the client tells you “…” What you assessed What you assessed What you did What you did What you taught What you taught

18 Focused Assessment Pain – people are different! Observe: grimacing, guarding, crying, Observe: grimacing, guarding, crying, irritable, shouting, cursing, etc. irritable, shouting, cursing, etc. or or stoic, denial, joking, etc. stoic, denial, joking, etc. Scale: subjective evaluation tool. Scale: subjective evaluation tool.

19 Be Pain Professional Pain is what the client says it is !!! Pain is what the client says it is !!! Don’t be punitive Don’t be punitive Don’t be passive-aggressive Don’t be passive-aggressive Beware of using clichés: Beware of using clichés: “Attention seeking” - “all behavior has meaning” “Drug Seeking” NO Vigilante Nursing “Drug Seeking” NO Vigilante Nursing -you won’t cure their habit -you won’t cure their habit -its not your job to detox them -its not your job to detox them -higher tolerance -higher tolerance

20 When You Call Give an Intelligent Report Clear, Concise, Accurate Mary Smith is the 26 y.o Caucasian female. She was admitted last night with an acute asthma flare. She is on solu-medol 60mg TID. No other pertinent history or known allergies. She is complaining of right throbbing mid calf pain, rate 10/10 that is continuous and has progressed over the last 6 hrs, aggravated by weight bearing and unrelieved by 650mg of Tylenol given 2hrs ago. Her lower right leg appears red, warm with an increased girth, Her vital signs 98.8, 24, 100, 140/92. She is lying in a fetal position crying, refusing food and fluid.

21 Neuro Check Pupil size Pupil size Upper & Lower Extremity Strength Upper & Lower Extremity Strength

22 Glasgow Coma Scale – Motor, Verbal, Eye (MVE-654) (MVE-654) Best Motor response 6 Best Verbal response 5 Eye opening 4 Highest score is 15 Highest score is 15 Lowest score is 3 Lowest score is 3 GCS < or = 8: Intubate GCS < or = 8: Intubate

23 Cranial Nerves Why do I have to know them ?

24 Because they are IMPORTANT Vision Vision Speech Speech Hearing Hearing Balance Balance Smell Smell Swallowing, taste, chewing Swallowing, taste, chewing Facial expression Facial expression Muscle movement Muscle movement

25 Cranial Nerves I O n II Old IIIOlympus IVTowering VTops VIA VIIFin VIIIAnd IXGerman XViewed XISome XIIHops

26 The Picture

27 Questions You are the intake nurse at the community clinic. You are going to do a physical assessment on a new client. Which of the following should be addressed first? You are the intake nurse at the community clinic. You are going to do a physical assessment on a new client. Which of the following should be addressed first? A. Vital signs B. Cough C. Appearance

28 A 78 year-old male is admitted to your unit with a diagnosis of bronchitis. What is your first priority as you perform his admission assessment? A 78 year-old male is admitted to your unit with a diagnosis of bronchitis. What is your first priority as you perform his admission assessment? A. Having him sign the admission form B. Establishing rapport C. Gathering necessary equipment

29 Your new admission tels you he is hearing a voice talking to him. How would you document this finding? Your new admission tels you he is hearing a voice talking to him. How would you document this finding? A. an illusion A. an illusion B. a delusion B. a delusion C. a hallucination C. a hallucination

30 During your assessment you notice During your assessment you notice you note the client has clubbed fingers. This is a sign of ? you note the client has clubbed fingers. This is a sign of ? A. Malnutrition B. Hypoxia C. Infection

31 In assessing pupils of unequal size knows the nurse understands it may be any of the following except: In assessing pupils of unequal size knows the nurse understands it may be any of the following except: A. Normal A. Normal B. caused by local trauma B. caused by local trauma C. caused by Brain trauma C. caused by Brain trauma D. Serve conjunctivitis D. Serve conjunctivitis

32 The stoke client you are caring for is having trouble chewing this may indicate a problem with cranial nerve: The stoke client you are caring for is having trouble chewing this may indicate a problem with cranial nerve: A. II B. V C. VII D. XI

33 When you auscultate the lower lobes When you auscultate the lower lobes of a healthy client, you would expect to hear: of a healthy client, you would expect to hear: A. bronchial sounds B. atelectic sounds C. vesicular sounds D. Crackle sounds

34 In assessing your new admission, which circulatory item would be a priority to report? In assessing your new admission, which circulatory item would be a priority to report? A. S 1 at the apex of the heart B. Capillary refill time of 3 seconds C. Friction rub when breath is held

35 Your client is complaining about “rumbling abdominal sounds”. Hyperactive Bowel sounds may indicate: Your client is complaining about “rumbling abdominal sounds”. Hyperactive Bowel sounds may indicate: A. Ileus B. Narcotic use C. Laxative use

36 In assessing the eyes of your client In assessing the eyes of your client with a pen light; you shine the light into the right eye. You should report a problem if the left eye: with a pen light; you shine the light into the right eye. You should report a problem if the left eye: A. constricts B. does not constrict C. blinks

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