Evaluating & Monitoring your Patient SG Flashcards
Pre-treatment Evaluation of your Patient
- What is pre-dialysis evaluation?
- review of the patients health before treatment begins
2. compares current health status to previous evaluations
Pre-treatment Evaluation of your Patient
- Why is the pre-evaluation of your dialysis patient needed?
- to determine if the patient is stable to receive treatment
- has there been any changes in health status
- provide baseline data to plan for a safe treatment
describe universal precautions:
the steps we take with all patient contact to decrease the risk of spreading infection to protect our patients and ourselves
What are the 3 C’s of patient evaluation?
Condition
complaints
changes
The condition of a patient is based on general findings of each of the following?
- Ambulation
- Mental status and mood
- Skin
- vital signs
ambulation:
What should you look for?
gait changes, use of any assistive devices, ROM, and energy level
Mental Status and Mood:
What should you look for?
aaox3
any changes in usual mood
Skin:
What should you look for?
color
integrity
temperature
edema
Vital Signs
What should you look for?
weight
BP
HR
Respirations
temperature
What is an EDW?
a patients weight with excess fluid removed
When is the Rn required to assess the patients pre-treatment weight?
if the pretreatment weight is 4kg above the EDW
What does the blood pressure measure?
measurement of the pressure or force of blood against the walls of the arteries
When do you report a blood pressure to the Rn
SBP <100 or > 200 DBP > 100
when do you report a HR to the RN?
new onset of HR less than 60 or greater than 100 or irregular
When do you report a respiratory rate to the RN?
greater than 24
true or false
does a dialysis patient maintain an average temperature
false
When do you report a temperature a temperature to the RN
less than 96
or = 100
name some important complaints that you need to report to the RN
- dizziness
- chest pain
- SOB
- any new complaints
- a visit to the ED or hospital stay
- weakness
- numbness and tingling
- fever and chills
- depression
- pain
What changes do you report to the RN
new meds or visits to the ED or hospital stay
communication of ALL abnormal findings are required to ensure ______
patient safety
What are your state specific guidelines on when a patient needs a pre-dialysis assessment
Tennessee requires that all patients need an assessment
Name the ABC’s of a patient assessment
Access
breathing
cardiac
Access:
describe what to look for:
bruises
redness
drainage
swelling
bruit
thrill
pain
bleeding
Breathing:
describe what to look for?
rate
rhythm
quality
SOB
breath sounds
cardiac
describe what to look for?
skin color and turgor
heart sounds
pulse rate
rhythm and quality
edema
pain
SOB
Why do patients experience crackles (rales) breath sounds?
indicates fluid or congestion in the lungs
Name some reasons for an abnormal heart rate?
can indicate chemical imbalances or adverse effects from medications
assessment of _____ is essential when you are evaluating a patient’s cardiovascular system?
EDEMA
name some places that fluid may get trapped
abdomen lungs feet legs hands face