1. Nursing Assessment

2. 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

3. Etiology of Disease hereditary congenital inflammatory degenerative
infectious
deficiency
metabolic
neoplastic
traumatic
environmental
diseases that have no apparent cause (unknown etiology)

4. 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.

5. Risk Factors and Development of Disease
Categories of risk factors
Genetic & Physiological
Age
Environment
Lifestyle

6. 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.

7. Perform assessment as soon after admission as possible.
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

8. The Interview -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

9. Biographical Data date of birth Sex address family members
marital status
religious preference
occupation
source of health care
insurance

10. 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

11. The Interview Past Health History Family 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

12. The Interview Environmental History Psychosocial /Cultural 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

13. Assessment Subjective data Identify symptoms -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

14. 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

15. 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

16. 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.

17. 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)

18. 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

19. 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

20. 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.

21. Head-to-Toe Assessment
Strength Testing
If pain or injury  begin with normal side
Compare one side to other
Score:
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”

22. 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.

23. 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.

24. -hear/follow commands. -hearing aids
Eyes
-symmetry.
-exudate/drainage
-sclera.
-pupillary reflex
-penlight
-PERRLA (Pupils Equal, Round, Reactive to Light and Accomodation)
Ears
-ear canal.
-hear/follow commands.
-hearing aids

25. Head-to-Toe Assessment
Breasts
-examine
-encourage monthly self-exams
Spine
-curvature
-sitting/standing position.

26. Head-to-Toe Assessment
Pulmonary System
Chest
-bilateral chest expansion.
-rate/rhythm of respirations.
-Breathing should be QUIET.
-posture.

27. 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

28. How does Respiration Occur?
Inspiration
Inspiration
Diaphragm

30. 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.

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

33. Anatomical Heart Position
Superior Vena Cava
Aorta
Pulmonary Artery
Anatomical Heart Position

34. Patient Positions for Auscultation of Heart Sounds
Sitting up, Leaning slightly forward
Left Lateral recumbent
Supine

35. 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

36. 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.

37. 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.

38. Palpation of arterial pulses
Femoral
Brachial
Radial
Posterior tibial
. Popliteal
Dorsalis pedis

40. 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

41. Palpation of the abdomen ----distention
-masses
- tenderness
Palpation of the liver.

42. Rectum Genitourinary system Skilled observation: Palpate
labia/genitalia
pubic hair.
Palpate
-suprapubic area.
-scrotum
-encourage regular self examination.
Rectum
assess for hemorrhoids / lesions.

43. Legs and Feet Palpate -femoral -dorsalis pedis -popliteal
-posterior tibial pulses.
Range of motion (ROM)
Color, Motion, Sensation (CMS)
Temperature

44. 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
-lasts as long as 2 to 5 minutes
If the edema is not pitting, it cannot be given a grade

45. Edema of the leg

46. Edema: It’s not just for legs !

47. Ending the Assessment Thank the patient. Wash your hands
Disinfect pen.
Document your findings thoroughly.
-Documentation does impact the quality of care given.
Report any significant changes or findings to the appropriate healthcare professional.

48. 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.

49. Quick Assessment (A B Cs)
A = Airway P = Pain
Includes comfort measures
B = Breathing S = Safety
Water and Call bell in reach
C = Circulation
In = What’s going in
Check IV patency
Infusion rates, machines and tubing
Out = What’s going out
Dressings
Chest tubes
Urinary drainage tubes