1JO2 Unit 8 Final Exam Flashcards
What is reviewed about the patient in TOA?
Reviews key details of patients health history relevant to the situation, admission history, complications, care goals,consults,infection control, allergies, code status, diet, IVs or feeds running, activity (i.e: independent, needs assist getting out of bed, bedrest, 2-person assist to get out of bed), shift orders/new orders, review medications ordered, review recent lab tests (bloodwork) or diagnostic test results (xrays, MRI), family/cultural considerations, review recent vital signs and any abnormal head-to-toe findings, and bedside safety check.
When should a head to toe assessment be performed?
At the beginning of each shift after TOA
How often should an admitted patient in the hospital recive a focused examination?
every 8hrs.
Before entering the room, what should you look for before you begin the head-to-toe assessment?
Are there any isolation precautions, allergy bands, fall precautions.
What is the general order of a head-to-toe assesment?
Introductions/General Appearance
Safety check
Vital signs/pain
Neurological
Respiratory
Cardiovascular
Skin
Abdomen
Genitourinary
Activity/MSK
What is the first thing that you should do before starting the head-to-toe assessment and but after you are in the room and have done the introduction.
Check the patients arm band and verify it with 2 patient identifier’s the name and DOB.
What are the 4 categories of a general survey in the head-to-toe assessment?
Appearance, body structure, mobility and behavior.
If vital signs have already been done in the previous shift, should the new nurse have to do vital signs? Even if the last time vital signs were done was 30mins ago?
Yes, each nurse should always do their own set of vitals
If there is an abnormal finding in the head-to-toe assessment, what should be done?
A focused health assessment that pertains to the abnormal finding.
What needs to be assessed the neurological portion of the head-to-toe assessment?
LOC, verbal response (is it clear and articulate?), measure pupil size (and asses if they are equal), asses motor response in upper and lower limbs, asses muscle strength bilaterally, asses ability to swallow.
What should the nurse do if the client is not opening their eyes spontaneously to voice?
They should further asses their LOC and perform the Glasgow coma scale.
What needs to be assessed the respiratory portion of the head-to-toe assessment?
Respiratory effort, asses the Fio2, auscultate anteriorly and posterior just as in the focused health assessment.
What does Fio2 mean?
Fraction of inspired oxygen.
What needs to be assessed the cardiac portion of the head-to-toe assessment?
Auscultate the apical pulse and compare its rate and rhythm with the radial pulse, auscultate heart sounds around the precordium with both the bell and diaphragm, check the capillary refill in finger tips, check for pre-tibial edema and Palpate pedal and posterior tibial pulses in both
feet.
What is a pulse deficit?
Its the difference between the apical and the radial pulse.
What does a pulse deficit indicate?
It means that there is a weak contraction of the ventricles and it happens in people with heart failure and atrial fibrillation.
What needs to be assessed the skin portion of the head-to-toe assessment?
Palpate the skin to asses for moisture and temperature, assess skin turgor, asses skin integrity and if there are any lesions, complete the Braden scale assessment, asses any IV sites.
What needs to be assessed for the abdomen portion of the head-to-toe assessment?
Assess the shape and color of the abdomen, auscultate for bowel sounds in all 4 quadrants, light palpation in all 4 quadrants, asses diet and tolerance, ask about nausea.
What needs to be assessed for the genitourinary portion of the head-to-toe assessment?
Asses 24hr fluid balance(Input and output), perform a bladder scan if necessary, assess Cathether and the surrounding area.
What needs to be assessed for the activity and MSK portion of the head-to-toe assessment?
If bed rest is ordered asses for skin breakdown, if patient is ambulatory asses for dizziness and orthostatic hypotension, asses their ability to move to the chair, their ability to turn and gait, asses the need for any ambulatory aids,
What angle should the bed be raised to if the patient is on bed rest?
15 degrees or higher.
