2 What are we looking for? Disease -disturbance of a structure or function of the body.-signs and symptoms.Signs: objective dataSymptoms: subjective dataclustered in groupsAssessment of signs and symptomsAssists the physician to make a medical diagnosisAssists the nurse in making the nursing diagnosis
3 Etiology of Disease hereditary congenital inflammatory degenerative infectiousdeficiencymetabolicneoplastictraumaticenvironmentaldiseases 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 conditionincreases the vulnerability of an individual to illness oraccident.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 factorsGenetic & PhysiologicalAgeEnvironmentLifestyle
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 diagnosisPerform assessment as soon after admission as possible.Initial assessment- Nurse and/or MD.Ongoing assessment –LPN/RNNurses are often the first to detect changes in the patient’s condition
8 The Interview -relaxed, unhurried manner. -quiet, private, well-lightedsetting.-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 statusreligious preferenceoccupationsource of health careinsurance
10 Reasons for Seeking Health Care Chief Complaint- patient’s own wordsOPQRST method:O = onset, duration of problemP = provocation/palliation: what makes it worse or better?Q= quality/quantityR =region/radiation- where it is, where it goesS = severityT = time: when the problem started, has it been constant
11 The Interview Past Health History Family History hospitalizations allergiesspecific reaction to antigenhabits and lifestyle patternsactivity of daily living’ (ADLs)sleep, exercise, and nutritionFamily HistoryImmediate/blood relatives-health-cause of death-history of illness
12 The Interview Environmental History Psychosocial /Cultural History home environmentPsychosocial /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; statesIdentify symptomsnurse unaware of symptoms unless the patient describes the sensationdescription 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 systemsRecord in clear and concise mannerUse appropriate terminologyAsk specific questionsAssess the functioning of each system
16 Head to Toe Assessment Items needed: WASH YOUR HANDS!! -penlight -stethoscope-blood pressure cuff-thermometer-gloves-tongue bladeSenses 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 FunctionAsk pt. to move each extremityAsk pt. to smile, frown, lift eyebrowsCheck Pupilary ResponseCheck for size, equality, and shape
19 Head-to-Toe Assessment Integumentary systemObserve 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/dryScalp should be free of dandruff, lesions, or parasites
20 Assessing Skin TurgorGrasp 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 TestingIf pain or injury begin with normal sideCompare one side to otherScore:0 = No Active Movement1 = Muscle contraction, no movement2 = Full Active ROM with gravity eliminated3 = Full Active ROM movement against gravity4 = Full active ROM against partial resistance5= Full active ROM overcome full resistanceDocumentationEg. -”Strength in upper extremity was 5/5”
22 Head-to-Toe Assessment Head and neckfacial expression.symmetry of features.arteries, veins, and lymph nodes.jugular vein distentionPalpate: -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
26 Head-to-Toe Assessment Pulmonary SystemChest-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? InspirationInspirationDiaphragm
30 Head-to-Toe Assessment Cardio-vascular SystemHeart soundsAuscultateintensity 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 soundsApex(Mitral)-fifth intercostal space-mitral and left heart sounds
33 Anatomical Heart Position Superior Vena CavaAortaPulmonary ArteryAnatomical Heart Position
34 Patient Positions for Auscultation of Heart Sounds Sitting up, Leaning slightly forwardLeft Lateral recumbentSupine
35 Heart Sounds Lubb: -long, low-pitched sound -closure of the Tricuspid and Bicuspid Valves-Systolic MurmurDupp:-short, sharper sound-closing of Pulmonary and Aortic Valves-Diastolic Murmur
36 Head-to-Toe Assessment Peripheral vascular systemPeripheral pulses- 8Strength on a 0-to-4+ scale0 = absent1+ = thready2+ = weak3+ = normal4+ = boundingExtremities-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 whitenote of the time needed for color to return once thenail is releasednormal capillary refill time is less the (<) 3 secondsCapillary Refill Time (CRT) is a common measure of peripheral perfusion.
38 Palpation of arterial pulses FemoralBrachialRadialPosterior tibial. PoplitealDorsalis pedis
40 Head-to-Toe Assessment AbdomenCheck for:Shape, lumps, contour,rashes, lesions, scarsAuscultate:Bowel Sounds in all quadrantsListen at least 1 min in each quadrantNote hyperactive vs diminished/absent soundsPalpation/Percussion
41 Palpation of the abdomen ----distention -masses- tendernessPalpation of the liver.
42 Rectum Genitourinary system Skilled observation: Palpate labia/genitaliapubic hair.Palpate-suprapubic area.-scrotum-encourage regular self examination.Rectumassess 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 rapidly2+ “Mild” -deeper pitting-no marked change in the shape of the extremity-disappears (“rebounds”) in 10 to 15 seconds3+ “Moderate” -noticeably deep pitting-very edematous and distorted extremity-last from 15 seconds-1 minute4+ “Severe” -very deep pitting-lasts as long as 2 to 5 minutesIf the edema is not pitting, it cannot be given a grade
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 = PainIncludes comfort measuresB = Breathing S = SafetyWater and Call bell in reachC = CirculationIn = What’s going inCheck IV patencyInfusion rates, machines and tubingOut = What’s going outDressingsChest tubesUrinary drainage tubes