skills lecture 3 Flashcards
When you are doing a physical exam assessment how do you know if a change has occured?
compare to previous assessment done
what do you use a physical exam for?
-gather baseline data on pts health status
-compare to other assessments for change
-supplement, confirm, or refute subjective data obtained
-identify and confirm nursing diagnoses
-make clinical decisions about pts changing health status and management
-evaluate the outcomes of care
-better understand pts physical, mental and emotions needs as well as their educational needs
how do you prioritize which resident you will see first?
ABCs
ways to prepare for an examination
-infection control, ppe, gloves, disinfect equipment
-ensuring privacy in the environment
-make sure equipment works
-physical preparation of pt
-psychological prep of pt, explain what youre doing
-assessment of age groups
-maintain privacy
-educate and answer questions before performing a task
-inform patient of what you are doing before you do it (dont ask)
the organization of the examination is
assessment of each body system
systematic and organized
head to toe approach
THINGS TO DO IN HEAD TO TOE APPROACH
-COMPARE SIDES FOR SYMMETRY
-ASSESS BODY SYSTEMS MOST AT RISK FOR BEING ABNORMAL
-OFFER REST PERIODS AS NEEDED
-PERFORM PAINFUL PROCEDURES AT THE END
-BE SPECIFIC WHEN RECORDING ASSESSMENTS
-RECORD QUICK NOTES DURING THE EXAM AND COMPLETE LARGER NOTES AT THE END
-TRY TO REMEMBER WHAT WAS ABNORMAL ON THE ASSESSMENT
WHAT ARE THE TECHNIQUES OF PHYSICAL ASSESSMENT?
-INSPECT - LOOK
-AUSCULTATION - LISTEN
-PALATION - FEEL
PERCUSSION
ALWAYS DO IN THIS ORDER
FACTORS INVOLVED IN INSPECTION (LOOK)
-OBSERVATIONS MADE WITH EYES EARS NOSE WHEN YOU WALK IN THE ROOM
-HAVE GOOD LIGHTING AND DIRECT LIGHTING TO INSPECT BODY CAVATIES
-WATCH FOR NONVERBAL EXPRESSIONS, ASSESS EMOTIONAL AND MENTAL STATUS, ASSESS PHYSICAL MOVEMENTS
-INSPECT EACH AREA FOR SIZE, SHAPE, COLOR, SYMMETRY, POSITION AND ABNORMALITY
-CHECK FOR SIDE TO SIDE SYMMETRY
-POSITION AND EXPOSE BODY PARTS AS NEEDED SO ALL SURFACES CAN BE VIEWED BUT PRIVACY MAINTAINS
FACTORS INVOLVED IN AUSCULTATION (LISTEN)
REQUIRES: GOOD HEARING, A GOOD STETHOSCOPE, KNOWLEDGE, CONCENTRATION AND PRACTICE
SOUND CHARACTERISTICS: FREQUENCY, LOUDNESS, QUALITY AND DURATION
FACTORS INVOLVED IN PALPATION (TOUCH)
-USES TOUCH TO GATHER INFO
-USE DIFFERENT PARTS OF HAND TO DETECT DIFFERENT CHARACTERISTICS
-HANDS SHOULD BE WARM AND FINGERNAILS SHORT
-START WITH LIGHT PALPATION AND END WITH DEEP PALPATION
-ALWAYS PALPATE THE TENDER AREAS LAST
FACTORS INVOLVED WITH PERCUSSION
-TAP SKIN WITH FINGERTIPS TO VIBRATE UNDERLYING TISSUES AND ORGANS
-SOUND DETERMINES LOCATION, SIZE, AND DENSITY OF STRUCTURES
-PERFORMED BY A MORE ADVANCED PROVIDER
FACTORS WITH GENERAL APPEARANCE AND BEHAVIOR ON PHYSICAL EXAM
GENDER
RACE
AGE
SIGNS OF DISTRESS
BODY TYPE
POSTURE
GAIT
MOVEMENTS
HYGEIN
DRESS
MOOD
SPEECH
SIGNS OF ABUSE
SUBSTANCE ABUSE
VITALS SIGNS
IF A PATIENTS WEIGHT IS UNDER OR OVER WEIGHT IT COULD BE SIGNS OF WHAT?
UNDER - DEHYDRATION
OVER - RETAINING FLUIDS
WHAT ARE THE LEVELS OF CONSCIOUSNESS AND WHAT IS THE SCALE USED CALLED?
AVPU
AWAKE AND ALERT
RESPONDS TO VERBAL STIMULI
RESPONDS TO PAINFUL STIMULI
UNCONSCIOUS
IS THE PATIENT IS AWAKE AND ALERT HOW WOULD THEY RESPOND?
PATIENT OPENS EYE SPONTANEOUSLY AND IS AWAKE AND RESPONDING
IS THE PATIENT RESPONDS TO VERBAL STIMULI HOW WOULD THEY RESPOND?
-NOT AWAKE AND ALERT
-RESPONDS, OPENS EYES OR AWAKENS WHEN SPOKEN TO
IS THE PATIENT RESPONDS TO PAINFUL STIMULI HOW WOULD THEY RESPOND?
NOT AWAKE AND ALERT
DOES NOT RESPOND TO VERBAL STIMULI
- RESPONDS/OPEN EYES/AWAKENS WHEN THEY FEEL PAIN
IF A PATIENT IS UNCONSCIOUS HOW DO THEY RESPOND?
THEY DONT
UNRESPONSIVE TO STIMULI
WHAT IS USED IF A PATIENT IS NOT RESPONSIVE?
GALSGOW COMA SCALE
WHAT DOES GLASGOW COMA SCLAE EVALUATE?
EYE OPENING RESPONE
VERBAL RESPONSE
MOTOR RESPONSE
WHAT IS THE BEST SCORE OF THE GLASGOW COMA SCALE AND WHAT DOES IT MEAN?
BEST SCORE - 15
MEANS - PATIENT IS AWAKE, ALERT, ORIENTED AND FOLLOWING COMMANDS APPROPRIATELY
WHAT IS THE WORST SCORE OF THE GLASGOW COMA SCALE AND WHAT DOES IT MEAN?
SCORE - 3
MEANS - TOTALLY UNRESPONSIVE
WHAT DOES A SCORE OF 8 OR LESS ON THE GLASGOW COMA SCALE?
PATIENT IS COMATOSE
LESS THAN 8 - INTUBATE
WHEN AND WHERE IS THE GLASGOW COMA SCALE USED?
THE SCALE IS USED INEMERGENCY SETTINGS AND INTENSIVE CARE UNITS MOST FREQUENTLY
WHAT ARE THE TWO MAIN THINGS THAT CAUSE CONFUSION IN A PATIENT?
HYOXIA AND INFECTION
WHAT IS INVOLVED IN PATIENT ORIENTATION?
-PERSON
-PLACE
-TIME
-SITUATION
IF A PATIENT IS ACUTELY CONFUSED, USE ________ _________ TO ATTEMPT TO REORIENT THEM
REALITY ORIENTATION
IF THE PATIENT IS CHRONICALLY CONFUSED (DEMENTIA), REORIIENTATION MAY CAUSE THE PATIENT TO BECOME ________
AGITATED
WHAT IS THE REASON TO ASSESS FOR ORIENTATION?
TO DETERMINE IF A PATIENT IS CONFUSED OR NOT
ASSESSMENT OF THE PUPILS
ASSESS PUPILLARY RESPONSE
SHAPE, SIZE, AND REACT TO LIGHT EQUALLY
HOW TO ASSESS THE SIZE OF THE PUPILS
LOOK AT THE PUPILS; ARE THEY EQUAL OR UNEQUAL IN SIZE?
IF UNEQUAL MUST DOCUMENT THE SIZE OF EACH PUPIL
IF THIS IS A NEW FIND CONTACT THE PROVIDER
HOW TO ASSESS THE SHAPE OF THE PUPILS
LOOK AT THE PUPILS ARE THEY ROUND OR DIFFERENT SHAPE
HOW TO ASSESS THE REACTIVITY TO LIGHT
USE A PEN LIGHT TO SHINE IN EACH EYE WHILE ASSESSING FOR PUPILLARY REACTION/RESPONSE OF THE PUPIL THAT THE LIGHT IS DIRECTED TOWARDS.
ARE THE PUPILS REACTIVE? NONREACTIVE BILATERALLY? NON-REACTIVE UNILATERALLY?
HOW TO ASSESS CONSENSUAL RESPONSE OF PUPILS
USE PEN LIGHT TO SHINE IN ONE EYE, LOOK AT THE OTHER EYE AND ASSESS FOR PUPILLARY REACTION/RESPONSE.
IS THE CONSENTING? IS IT CONSTRICTING, JUST LIKE THE PUPIL WITH THE LIGHT SHINING IN IT IS? IF YES, CONSENSUAL RESPONSE IS PRESENT
CONSENSUAL RESPONSE: PRESENT? NOT-PRESENT BILATERALLY? NOT PRESENT UNILATERALLY?
HOW TO ASSESS ACCOMMODATION OF PUPILS
HOLD AND OBJECT CLOSE TO FACE AND HAVE PATIENT FOCUS ON IT, THEN HAVE THEM LOOK AT AN OBJECT FAR AWAY, THEN FOCUS BACK ON THE OBJECT CLOSE TO THEIR FACE
THE PUPILS SHOULD CONSTRICT WHEN FOCUSING ON AN OBJECT UP CLOSE, DILATE WHEN FOCUSING ON A FAR AWAY OBJECT
CAN ONLY ASSSESS THIS IF THE PATIENT IS COOPERATIVE. PRESENT OR NOT?
IF FINDINGS OF PUPILS ARE WITHIN APPROPRIATE LIMITS WHAT IS IT CALLED?
PERRLA WITH CONSENSUAL RESPONSE PRESENT
WHAT DOES PERRLA STAND FOR?
PUPILS EQUAL ROUND REACTIVE TO LIGHT WITH ACCOMMODATION
(AND CONSENSUAL RESPONSE)
If the patient is unable to perform accommodation HOW WOULD YOU DOCUMENT?
Must document everything and then describe why you’re unable to assess accommodation
Pupils equal round reactive to light with consensual response. Unable to assess accommodation, patient unable to follow commands
WHAT IS INVOLVED IN AN ASSESSMENT OF SPEECH?
PATTERNS AND SOUNDS
COMMUNICATION ABILITIES
APHASIA (INABILITY TO COMMUNICATE)
WHAT ARE THE CHARACTERISTICS OF SPEECH PATTERNS/SOUNDS?
CLEAR
SLURRED
GARBLED
ABSENT (NONVERBAL)
WHAT ARE THE CHARACTERISTICS OF SPEECH COMMUNCATION ABILITIES?
LOGICAL
ILLOGICAL
WHAT ARE THE CHARACTERISTICS OF SPEECH APHASIA
Sensory/receptive
Patient doesn’t understand the words being spoken to them. They are able to speak clearly, may be illogical
Motor/expressive – CANNOT SPEAK BUT RECEPTIVE
Patient cannot expressive themselves using verbal communication. They have difficulty forming words, their speech may be slurred and/or garbled. They are usually receptive of communication.
ASSESSMENT OF THE HEAD AND FACE INCLUDES
INSPECT
EENT
WHAT IS INVOLVED IN AN INSPECTION OF THE HEAD AND FACE?
-POSITION, SIZE AND SHAPE
-SYMMETRICAL FACIAL FEATURES
WHAT IS INVOLVED IN AN EENT ASSESSMENT?
EARS
EYES
NOSE
THROAT
WHAT IS INVOLVED IN AN EAR ASSESSMENT?
-CHECK INSIDE THE EARS FOR DRAINAGE
-DOES THE PATIENT WEAR HEARING AIDS?
-ANY HEARING DIFFICULTIES
IF A PATIENT HAS TROUBLE HEARING HOW SHOULD YOU CHANGE THE ASSESSMENT?
-QUIET AREA
-SPEAK UP
-SPEAK IN SHORT PHRASES
-GIVE RESIDENT TIME TO RESPOND
WHAT IS INVOLVED IN AN EYE ASSESSMENT?
-EYE LIDS
-SCLERA
-GLASSES
WHAT ARE YOU ASSESSING WHEN LOOKING AT THE EYE LIDS?
SWELLING
WHAT ARE YOU LOOKING AT WHEN ASSESSING THE SCLERA?
COLOR
WHITE - NORMAL
YELLOW- JAUNDICE
PINK - CONJUNCTIVA, IRRITATION
RED - IRRITATION, HEMORRHAGE OF VESSELS IN EYE
WHEN ASSESSING A RESIDENT YOU ARE CHECKING THEIR EYES. UPON QUESTIONING THE RESIDENT STATES THEY HAVE GLASSES BUT LEFT THEM AT HOME. WHAT WOULD THE NURSE DO WHEN ASSESSMENT IS OVER?
CONTACT SOMEONE THAT CAN BRING THE RESIDENT THEIR GLASSES
WHAT DOES AN ASSESSMENT OF THE NOSE INVOLVE?
SEPTUM
NARES
WHAT ARE YOU LOOKING FOR WHEN ASSESSING SEPTUM?
-MIDLINE
-DEVIATED
WHAT ARE YOU LOOKING FOR WHEN ASSESSING NARES?
-PATENT
-OCCLUDED
HOW DO YOU DETERMINE THE PATENCY OF EACH NARIS INDIVIDUALLY?
HAVE THE PATIENT OCCLUDE A NARIS AND BREATHE IN THROUGH THE NOSTRIL THEN REPEAT WITH THE OTHER SIDE
WHAT IS INVOLVED IN THE ASSESSMENT OF LIPS?
color
integrity
WHAT IS INVOLVED IN THE ASSESSMENT OF TEETH?
DENTURES?
TEETH PRESENT OR NOT PRESENT
IMPLORTANCE OF ORAL HYGEINE
IF A PATIENT IS MISSING ALL OF THEIR TEETH WHAT IS THIS CALLED?
EDENTULOUS
WHAT IS INVOLVED IN THE ASSESSMENT OF ORAL MUCOSA?
COLOR
MOISTURE
INTEGRITY
WHAT IS INVOLVED IN THE ASSESSMENT OF THE THROAT
CAROTID ARTERY AND JUGULAR VEIN
IF YOU CAN SEE THE JUGULAR VEIN DISTENDED WHEN SITTING IN SEMI OR HIGH FOWLERS POSITION WHAT DOES THIS INDICATE?
FLUID VOLUME OVERLOAD
HYPERVOLEMIA
MECHANISMS OF RESPIRATIONS?
VENTILATION
DIFFUSION
PERFUSION
WHAT OCCURS DURING VENTILATION?
MOVEMENT OF GASES INTO AND OUT OF THE LUNG, INVOLVES INSPIRATION AND EXPIRATION
WHAT OCCURS DURING DIFFUSION?
MOVEMENT OF OXYGEN AND CARBON DIOXIDE BETWEEN ALVEOLI AND RED BLOOD CELLS
WHAT OCCURS DURING PERFUSION?
DISTRIBUTION OF RED BLOOD CELLS TO AND FROM THE PULMONARY CAPILLARIES
WHAT ARE YOU LOOKING FOR WHEN ASSESSING RESPIRATIONS?
-RESPIRATORY RATE
-VENTILATORY EFFORT
-VENTILATORY PATTERN
IF RESPIRATIONS ARE CONTINUOUSLY SHALLOW OR DEEP WHAT ELSE SHOULD YOU ASSESS?
RESPIRATORY DISTRESS
JUST EXERCISED
WINDED
ANXIETY ATTACH
HYPERVENTILATING
WHAT AFFECTS RESPIRATIONS?
-CURRENT OUTPUT
-EXERCISE
-ANXIETY
-AGE
WHAT IS INVOLVED IN A RESPIRATORY ASSESSMENT?
INSPECTION
AUSCULTATION
WHAT IS INVOLVED IN AN INSPECTION OF RESPIRATORY ASSESSMENT?
USE EYES TO SEE:
-RATE, PATTERN, EFFORT
-POSITIONING
-COLOR OF LIPS, FINGER TIPS
-IS PATIENT WEARING OXYGEN IF SO WHAT DEVICE DO THEY USE AND HOW MANY LITERS
WHAT IS INVOLVED WITH AUSCULTATION ON A RESPIRATORY ASSESSMENT?
Listen to lung sounds in all five lobes, anteriorly and posteriorly
Always listen symmetrically before moving to a different lobe
Sit patient in high Fowler’s position
Instruct patient to take a deep breath in and out through the mouth, each time you move your stethoscope
THINGS TO REMEMBER WHEN AUSCULTATING THE LUNGS?
When listening to anterior lower lobes, may need to ask women with large, pendulous breasts to lift them up, or have them raise their arms above their head (if they’re able to)
When listening to posterior upper lobes, be sure you are not listening over the scapula or the spine
When listening to posterior lower lobes, don’t go down too far (i.e. over the kidneys)
LUNG SOUNDS OF RESPIRATORY ASSESSMENT
-CLEAR
-DIMINISHED
-CRACKLES - FINE OR COURSE
-RHONCHI
-WHEEZES
-STRIDOR
-ABSENT
WHAT IS AN ADVENTIOUS SOUND OF THE LUNGS?
ANYTHING THAT IS NOT NORMAL WHEN ASSESSING THE LUNGS
IF YOU HEAR ADVENTIOUS LUNG SOUNDS WHAT MUST YOU DOCUMENT?
-DOES IT OCCUR ON INSPIRATION, EXPIRATION OR BOTH
-WHICH LOBE(S) DID YOU HEAR IT IN
-DID YOU ATTEMPT TO CLEAR IT WITH A COUGH AND WAS IT SUCCESSFUL OR NOT
CHARACTERISTICS OF COARSE CRACKLE LUNG SOUNDS AND CAUSE
MOIST BUBBLE SOUND, HEARD ON INSPIRATION AND EXPIRATION
CAUSE - FLUID IN AIRWAY
CHARACTERISTICS OF FINE CRACKLE LUNG SOUNDS AND CAUSE
VELCRO BRING TORN APART, HEARD AT END OF INSPIRATION
CAUSE- ALVEOLI POPPING OPEN ON INSPIRATION
CHARACTERISTICS OF WHEEZES ON LUNG SOUNDS AND CAUSE
FINE HIGH-PITCHED VIOLINS MOSTLY ON EXPIRATION
CAUSE- NARROWED AIRWAYS
*TYPICALLY WITH ASTHMA
CHARACTERISTICS OF STRIDOR LUNG SOUNDS AND CAUSE
LOUD CROWING NOISE HEARD WITHOUT STETHOSCOPE
CAUSE- AIRWAY OBSTRUCTION
CHARACTERISTICS OF DIMINISHED LUNG SOUNDS AND CAUSE
FAINT LUNG SOUNDS
CAUSES- DECREASED AIR MOVEMENT
CHARACTERISTICS OF ABSENT LUNG SOUNDS AND CAUSE
NO SOUNDS HEARD
CAUSE- NO AIR MOVEMENT
CHARACTERISTICS OF RHONCHI LUNG SOUNDS AND CAUSE
LOW PITCHED RATTLING SOUND, SIMILAR TO SNORING
CAUSE - OBSTRUCTION, SECRETIONS
*IF CLEARS WITH A COUGH IT IS CAUSED BY SECRETIONS
Patient has respiratory rate that is outside of expected normal values, breathing pattern is irregular, Depth of respirations increases or decreases, patient complains of dyspnea. What is your first step?
Observe for related factors such as obstructed airway; assess for abnormal breath sounds, productive cough, SOB, restlessness, irritability, anxiety, confusion
Patient has respiratory rate that is outside of expected normal values, breathing pattern is irregular, Depth of respirations increases or decreases, patient complains of dyspnea. What is your second step?
Help patient to supported sitting position (high Fowlers or tripod) unless contraindicated, which improves ventilation.
Patient has respiratory rate that is outside of expected normal values, breathing pattern is irregular, Depth of respirations increases or decreases, patient complains of dyspnea. What is your third step?
provide oxygen as ordered
titrate oxygen slowly until respiratory status improves
Patient has respiratory rate that is outside of expected normal values, breathing pattern is irregular, Depth of respirations increases or decreases, patient complains of dyspnea. What is your forth step?
report and document
Patient has respiratory rate that is outside of expected normal values, breathing pattern is irregular, Depth of respirations increases or decreases, patient complains of dyspnea. What is your fifth step?
continually reassess
what is involved in a cough assessment?
how frequent is the cough
how long has the cough been present
is it producing sputum
if cough is present assess cough abilities
characteristics of sputum production
coughing anything up
color: clear, yellow, green, pink, red (hemoptysis)
consistency: thick or thin
what things should be encourage if sputum production is present?
deep breathing and coughing
fluids to thin secretions
how will you assess coughing abilities if cough is present?
ask pt to cough
is cough weak or strong
if weak: encourage deep breathing to stimulate a stronger cough reflex and increase water to thin secretions
A patient is admitted with pneumonia. When auscultating the patient’s chest, you hear low-pitched, continuous rattling sounds over the bronchi. These sounds are labelled as:
Course crackles.
Fine crackles
Rhonchi
Wheezes
Clear
Diminished
rhonchi
assessment of the cardiovascular system involves:
-Heart sounds: S1 (LUB); S2 (DUB
assessment of heart sounds
Listen for at least 15 seconds to determine rate and rhythm regularity
Listening for loudness of heart sounds, heart rate and heart rhythm
characteristics of the loudness of heart sounds
strong or distant
characteristics of the rate of heart sounds
regular and irregular
characteristics of the rhythm of heart sounds
regular or irregular
If heart rate and/or rhythm are outside of normal finding expectations what must the nurse assess?
apical pulse for one full minute
heart rate <60bpm
bradycardia
heart rate >100bpm
tachycardia
what is it called when the heart rhythm is irregular?
dysrhythmia
what are the signs and symptoms of a dysrhythmia?
lightheaded and dizzy
are blood pressure and respiratory rate/effort normal or abnormal
how do you find the apical pulse?
- Have the patient sit or lay down
- Find the sternal notch, located in between the clavicles
- Find the angle of louis, right below the sternal notch
- Move your hand slightly to their left side, and begin to count intercostal spaces (you begin at space #2)
- Once you find the fifth intercostal space, move your hand so that it is midclavicle
- Place the diaphragm of your stethoscope in this location, place firmly and securely on chest
- Each “lub-dub” is one beat, count for 60 seconds to determine accurate heart rate
what is the difference between the radial and apical pulse called?
pulse deficit
Apical or radial pulse is greater than 100 beats/min what do you do?
Identify related data, including fever, anxiety, pain, recent exercise, hypotension, decreased oxygenation, or dehydration
Observe for signs and symptoms of inadequate cardiac output, including fatigue, chest pain, orthopnea, cyanosis, and dizziness.
Report and document
Apical or radial pulse is less than 60 beats/min what do you do?
Assess for factors that alter heart rate such as beta-blockers and antidysrhythmic medications.
Observe for signs and symptoms of inadequate cardiac output, including fatigue, chest pain, orthopnea, cyanosis, dizziness.
Report and document
Apical or radial pulse irregular
Observe for symptoms associated with decreased tissue perfusion, including pallor and cool skin temperature of tissue distal to the weak pulse.
Measure apical and radial pulse simultaneously to determine presence of pulse deficit.
Report and document
when doing a head to toe assessment why is the abdominal assessment so complex?
because the organs are located in the abdominal cavity
an abdominal assessment includes which systems?
-gastrointestinal system
-genitourinary system
-reproductive system in females
how to do an abdominal inspection
-place pt in supine position (can be done sitting down but if abnormal move pt to supine position
-lift clothing to assess bare stomach
-inspect shape of stomach
when inspecting the shape of the stomach what are you looking for?
-non-distended - flat, round
-distended - round and firm, tight
-masses
-enlarged organs - bladder or intestines fill
-also look for: movements or pulsations, colostomy, wounds, bruising, incisions
AUSCULTATION OF THE ABDOMEN
-LISTEN FOR MOVEMENT OF CONTENTS THROUGH THE BOWELS (PERISTALSIS) IN A CLOCKWISE PATTERN
-Place your stethoscope on the RLQ and begin clock at 0. When first bowel sound is heard, stopwatch time. That is how long the bowel sounds are in that quadrant.
HOW DO YOU CATEGORIZE BOWEL SOUNDS?
NORMOACTIVE
HYPOACTIVE
HYPERACTIVE
ABSENT
NORMAL BOWEL SOUNDS CONSIST OF CLICKS AND GURGLES AND OCCUR 5 TO 34 PER MINUTE
NORMOACTIVE
3 TO 5 BOWEL SOUNDS PER MINUTE; SEEN WITH DECREASED BOWEL MOTILITY
HYPOACTIVE
BOWEL SOUNDS GREATER THAN 34 SOUNDS PER MINUTE CAUSED BY ANXIETY, INFECTIOUS, DIARRHEA, IRRITATION OF INTESTINAL MUCOSA FROM BLOOD OR GASTROENTERITIS
HYPERACTIVE
NO BOWEL SOUNDS AFTER LISTENING FOR 5 MINUTES CONTINOUSLY IN ONE QUADRANT AND IS CAUSED BY AN IMMOBILE BOWEL
ABSENT
PALPATION OF ABDOMEN
LIGHTLY PALPATE INN A CLOCKWISE MANNER USUALLY START IN THE RIGHT LOWER QUADRANT OR RIGHT UPPER QUADRANT
PRIOR TO PALPATING THE ABDOMEN WHAT SHOUDL YOU ASK THE PATIENT?
IF THEY ARE EXPERIENCING ANY PAIN
IF SO PALPATE THE AREA LAST
WHAT DOES PALPATION DETECT?
TENDERNESS
DISTENTION
MASSES
IF YOU PALPATE ABDOMEN BEFORE YOU AUSCULTATE WHAT COULD HAPPEN?
DISRUPT THE BOWEL
ADDITIONAL QUESTIONS ABOUT CHARACTERISTICS OF BOWELS
BOWEL ELIMINATION
N/V, DIARRHEA OR CONSTIPATION
LAST BOWEL MOVEMENT
BOWEL CHARACTERISTICS
BOWEL COLOR
GASTRIC TUBE PRESENT
WHAT DO YOU NEED TO KNOW WHEN ASKING A RESIDENT ABOUT BOWEL ELIMINATION
CONTINENT
INCONTINENT
COLOSTOMY OR ILLESTOMY PRESENT
WHAT DO YOU NEED TO KNOW WHEN ASKING A RESIDENT ABOUT N/V, DIARRHEA OR CONSTIPATION
WHEN DID IT START
FREQUENCY
ABILITY TO KEEP FLUIDS IN
WHAT DO YOU NEED TO KNOW WHEN ASKING A RESIDENT ABOUT LAST BOWEL MOVEMENT
WHEN WAS IT
WHAT ARE THE RESIDENTS REGULAR BOWEL HABITS
WHAT DO YOU NEED TO KNOW WHEN ASKING A RESIDENT ABOUT BOWEL CHARACTERISTICS
SOFT
FIRM
HARD
LOOSE
WATERY
WHAT DO YOU NEED TO KNOW WHEN ASKING A RESIDENT ABOUT BOWEL COLOR
BROWN
GREEN
BLACK
RED
WHAT DO YOU NEED TO KNOW WHEN ASKING A RESIDENT ABOUT PRESENT GASTRIC TUBE
NG TUBE
PEG TUBE
ASSESSMENT OF THE BLADDER INCLUDES:
INSPECTION
PALPATE TO SEE IF BLADDER DISTENTION IS PRESENT
URINE ELIMINATION
ASSESSMENT OF URINE ELIMINATION
CONTINENT OR INCONTINENT
LAST VOID
IF A PATIENT IS INCONTINENT WHAT ARE THEY AT RISK FOR?
-SKIN BREAKDOWN OF THE PERINEAL, BUTTOCKS, COCYX AND SACRUM
-UTI
HOW OFTEN SHOULD AN INCONTINENT RESIDENTS BRIEF BE CHECKED
EVERY TWO HOURS
CHARACTERISTICS OF URINARY OUTPUT
COLOR
CLARITY
ODOR
DYSURIA
AMOUNT
IF A PATIENT HAS AN INDWELLING CATH PRESENT WHAT SHOULD YOU ASSESS FOR?
URINE OUTPUT, KINKS IN TUBING
ASSESS INSERTION SITE FOR REDNESS, IRRITATION OR DRAINAGE
IF OUTPUT OF URINE IS BEING MEASURED HOW DO YOU RECORD IT WHEN DOCUMENTING?
IN MILLIMETERS
IF A PATIENT IS INCONTINENT HOW DO YOU RECORD URINATION OUTPUT?
BY OCCURENCES
(X1 OCCURENCE)
what assessment is performed to evaluate sensory and motor function along with peripheral circulation of the extremities
neurovascular assessment
what is checked during a neurovascular assessment?
capillary refill
peripheral pulses
temp
color
edema
able to feel touch
numbness
tingling
SWELLING IN DEPENDENT EXTREMITIES DUE TO FLUID BUILD UP/FLUID OVERLOAD CAUSED BY FLUID LEAKING FROM VASCULAR SYSTEM TO TISSUES
PERIPHERAL EDEMA
TYPES OF EDEMA
PITTING
NON-PITTING
PITTING EDEMA SCALE:
1+ - MILD DISAPPEARS RAPIDLY
2+ - MODERATE; DISAPPEARS IN 10-15 SECONDS
3+ 0 MODERATELY SEVERE DISAPPEARS IN ABOUT A MINUTE
4+ SEVERE CAN LAST MORE THAN 2 MINUTES
HOW IS NON PITTING EDEMA MEASURED
TAPE MEASURE THE CIRCUMFERENCE OF THE SWOLLEN AREA
PERIPHERAL PULSE NEEDS TO BE DONE HOW TO THE BODY?
SYMMETRICALLY
HOW DO YOU DOCUMENT THE PULSE STRENGTH?
0 - ABSENT
1+ WEAK
2+ STRONG
3= BOUNDING
IF A PATIENT HAS A BOUNDING PULSE WHAT DOES THIS INDICATE?
FLUID OVERLOAD
IF A PATIENT HAS AN ABSENT PULSE STRENGTH WHAT DOES THIS INDICATE
NO BLOOD FLOW TO DISTAL EXETREMITY
THIS IS AN EMERGENCY AND PROVIDER NEEDS TO BE NOTIFIED IMMEDIATELY
IF A PATIENT HAS A WEAK PULSE WHAT DOES THIS INDICATE?
PERPHERAL VASCULAR DISEASE (DECREASED BLOOD FLOW), DECREASED CARDIAC OUTPUT
IF A PATIENT HAS A STRONG PULSE WHAT DOES THIS INDICATE?
NORMAL.APPROPRIATE FINDING
WHICH PULSE IS NOT PALPATED SIMULTANEOUSLY?
CAROTID PULSES
6 Ps of arterial occlusion
pain
parethesia
pallor
paralysis
pulselessness
poikilothermia
While this is expected with a muscle injury, pain described as deep and constant and poorly localized, that increases when stretching or manipulating the muscle, and is unrelieved by pain medications is not normal! What is this a sign of?
pain with an arterial occlusion
The patient may experience a pins-and-needles sensation, tingling, tickling, prickling or burning. Due to lack of oxygen supply to tissue/muscle. what is this a sign of?
paresthesia with an arterial occlusion
If you notice that your patient has pale, shiny skin, especially distal to the injury site, report the symptoms to a doctor immediately. Due to lack of oxygen supply to tissue/muscle. What is this a sign of?
pallor with arterial occlusion
numbness in a limb can be a sign of arterial occlusion. This is most common when a patient’s leg or arm has been crushed in an accident. what is this a sign of
paralysis with an arterial occlusion
A diminished or absent pulse in an affected area which creates a tourniquet-like effect and cuts off circulation to the limb. Due to lack of oxygen supply to tissue/muscle
pulselessness with an arterial occlusion
This term, which refers to a body part that regulates its temperature with surrounding areas, is an important one. If you notice a limb that feels cooler than surrounding areas. what is this a sign of?
poikilothermia with an arterial occlusion
Because of an older adults skin becoming frail what should you be cautious of putting on their skin?
tape
what is involved in an overall assessment of the skin?
color
temp
moisture
integrity
turgor
edema
IF A PATIENT’S SKIN IS DUSKY IN COLOR WHAT CAN THAT INDICATE?
HYPOXIA
IN A CLINICAL SETTING YOU WILL SEE RESIDENTS RANGE OF MOTION WHEN THEY DO WHAT
ADLS
A PATIENT CAN MOVE EXTREMITIES ON THEIR OWN
ACTIVE RANGE OF MOTION
PATIENT CANNOT MOVE EXTREMITIES ON THEIR OWN, NEED ASSISTANCE
PASSIVE RANGE OF MOTION
EXTREMITIES HAVE NO LIMITATIONS ON MOVEMENT
FULL RANGE OF MOTION
EXTREMITIES HAVE LIMITATIONS ON MOVEMENT, CAN ONLY MOVE TO A PARTICULAR POSITION AND THEN RESISTANCE NOTE, MOVE EXTREMITY/JOINT JUST TO THE POINT OF RESISTANCE, THEN STOP
PARTIAL RANGE OF MOTION
STIFF BODY PARTS THAT DO NOT MOVE, USUALLY FROM ATROPHY OF MUSCLES AND LACK OF USE, OCCURS WHEN PARALYZED
CONTRACTURES
WHEN ASSESSING PATIENTS ABILITIES TO MOVE WHAT QUESTIONS NEED TO BE ASKED?
RECENT FALLS?
ASSISTIVE DEVICES?
HOW DOES THE PATIENT TRANSFER FROM BED TO CHAIR
WHAT DO YOU NEED TO ASK PATIENT BEFORE AMBULATING?
RECENT FALLS
ASSISTIVE DEVICES
TRANSFER ABILITIES
DIZZY OR LIGHTHEADED
DO THEY FEEL COMFORTABLE WALKING
PAIN
TRANSFER TECHNIQUES
USE A GAITBELT
SAFE ENVIRONMENT
1 PERSON
2 PERSON
STAND BY ASSIST
MECHANICAL LIFT
ACTIVITIES OF DAILY LIVING
BATHING
DRESSING
TOILETING
BRUSHING TEETH
BRUSH HAIR
FEEDING SELF
BEHAVIOR IN AN ASSESSMENT
APPROPRIATE OR NOT APPROPRIATE TO SITUATION
-VULGAR, RUDE OR HOSTILE, CURSING
CAN CHANGE THROUGHOUT SHIFT IF IT DOES DOCUMEENT IN THE NARRATIVE
MOOD IN ASSESSMENT
CALM
ANXIOUS
FLAT/WITHDRAWN
TEARFUL
AGITATED
-CAN CHANGE THROUGHOUT THE SHIFT IF IT DOES DOCUMENT IN THE NARRATIVE
PSYCHOSOCIAL ASSESSMENT
CURRENT SMOKER
CURRENT ALCOHOL USE
CURRENT DRUG USE
KEEP ______ A PRIORTY WHEN WORKING WITH PATIENT
SAFETY
EXAMPLES OF SAFETY MEASURES NURSE NEEDS TO CHECK
SIDE RAILS
WHEELCHAIR LOCKED
FULL MAT IN PLACE
BED/CHAIR ALARMS
SAFETY MEASURES WHEN TRANSFERRING A PATIENT
KNOW THE PTS LIMITATIONS
DEETERMINE IF YOU NEED ASSISTANCE
ASK PT TO HELP AS MUCH AS POSSIBLE
DETERMINE IF PT COMPREHENDS WHAT IS EXPECTED
SAFETY MEASURE WITH OXYGEN
IS PT USING O2
IS TANK FULL
NO SMOKING WITH O2
MAKE SURE PT DOES NOT FALL ON TUBING
HOW OFTEN DOES SAFETY NEED TO BE DOCUMENTED?
AT LEAST EVERY TWO HOURS
WHAT AFFECTS DOES PHYSICAL ACTIVITY HAVE ON A PERSON?
ELEVATES MOOD AND ATTITUDE
ENABLES PHYSICAL FITNESS
HELPS ONE TO QUIT SMOKING AND STAY TOBACCO FEE
BOOSTS ENERGY LEVELS
HELPS IN THE MANAGEMENT OF STRESS
PROMOTES A BETTER QUALITY OF SLEEP
IMPROVES SELF IMAGE AND SELF CONFIDENCE
decrease in the ability to perform self care or ADLs. If you don’t use it you lose it. Allow resident to do what the can.
FUNCTIONAL DECLINE
WHAT CAUSES FUNCTIONAL DECLINE
ILLNESS
PHYSICAL INACTIVITY
any movement produced by skeletal muscles that results in energy expenditure
PHYSICAL ACTIVITY
a subset of PA that is planned, structured, and repetitive and has a final or an intermediate objective, such as the improvement or maintenance of physical fitness
PHYSICAL EXERCISE
PROPER BODY ALLIGNMENT ALLOWS FOR A STABLE _____ __ _______
CENTER OF GRAVITY
HOW SHOULD A PATIENT BE MOVED IN THE BED?
WITH TWO PEOPLE USING A DRAW SHEET TO AVOID SKIN TEARS
________ SYSTEM AND __________ system must work together to produce coordinated body movement
MUSCOSKELETAL AND NERVOUS
WHAT IS THE NUMBER ONE WAY TO PREVENT OSTEOPORISIS
MOVEMENT AND EXERCISE
WHAT DO PARALYZED PATIENTS WITHOUT ACTIVE MUSCLE MOVEMENT EXPERIENCE?
MUSCLE ATROPHY AND CONTRACTURES
THE GOAL FOR NURSING IS TO BEGIN PASSIVE ROM EXERCISES FOR PATIENTS THAT LOSE THE ABILITY TO MOVE A CERTAIN MUSCLE IS WHEN?
AS SOON AS THEY LOSE THE ABILITY
WHAT IS SPHM?
SAFE PATIENT HANDLING AND MOBILITY
WHAT IS SAFE PATIENT HANDLING AND MOBILITY USED FOR?
IMPROVES ASSESSMENT, THE USE OF MECHANICAL EQUIPMENT, AND SAFETY PROCEDURES TO LIFT AND MOVE PATIENTS
STANDARD FOR BEST PRACTICES IN THE MOVING, HANDLING, AND TRANSFER OF PATIENTS
REDUCES INJURIES TO HEALTH CARE WORKERS AND IMPROVES PATIENT OUTCOMES
WHAT DOES SPHM PREVENT?
FALLS
SKIN TEARS
PRESSURE INJURIES
HOW MANY PEOPLE ARE NEEDED TO USE A LIFT TO TRANSFER PATIENTS?
A MINIMUM OF TWO PEOPLE
THINGS TO REMEMBER WHEN USING A LIFT
EDUCATE PATIENT
UNDERSTAND HOW LIFT WORKDS
ENSURE BATTERY IS CHARGED
ENSURE ENOUGH PEOPLE PRESENT TO HELP
THINGS TO REMEMBER WHEN TRANSFERRING AND POSITIONING PT?
MAKE SURE PT IS SAFE
MAKE SURE PT IS COMFORTABLE
WHAT SHOULD BE IMPLEMENTED WHEN USING MOBILITY
ENCOURAGE PHYSICAL ACTIVITY AS OFTEN AS POSSIBLE
ISOMETRIC EXERCISES
RANGE OF MOTION EXERCISES
AMBULATE PT
IF A PATIENT IS IMMOBILE WHAT ORGANS CAN IT AFFECT?
HEART AND LUNGS
WHEN A PATIENT BEGINS TO FALL WHEN AMBULATING WHAT SHOULD THE NURSE DO?
HELP LOWER PT TO THE GROUND DO NOT ATTEMPT TO CATCH THEM
TYPES OF ASSISTED DEVICES FOR AMBULATING
WALKER
CANE
QUAD CANE
gaitbelt
WHAT IS A WALKER USED FOR?
EXTREMITY WEAKNESS OR BALANCE ISSUES
HOW TO USE A WALKER
GRIP HANDLBARS, TAKE A STEP, MOVE WALKER FORWARD THEN TAKE ANOTHER STEP
CANES SUPPORT
LESS SUPPORT THAN WALKER AND LESS STABLE
HOW TO USE A CANE
ADVANCE CANE FORWARD AND POSITION ON GROUND, STEP FORWARD WITH WEAKER LEG (SO BODY WEIGHT IS DIVIDED BETWEEN CANE AND STRONG LEG)
THEN ADVANCE STRONGER LEG PAST CANE SO WEAKER LEG AND BODY WEIGHT ARE SUPPORTED AGAIN
QUAD CANE SUPPORT
PROVIDES THE MOST SUPPORT AND IS USED WITH PARTIAL OR COMPLETE LEG PARALYSIS OR HEMIPLEGIA
WHO HAS TO ORDER ASSISTIVE DEVICES
DR OR PHYSICAL THERAPIST
PHYSICAL THINGS THAT IMMOBILITY CAUSES
LUNGS
HEART
SKIN
EMOTIONAL STATUS CHANGES
Therapeutic intervention that restricts patients to bed:
DECREASED OXYGEN DEMANDS OF THE BODY, ALLOWS BODY TISSUE TO HEAL
DECREASED CARDIAC WORKLOAD AND PAIN
ALLOWS PATIENT TO REST
Effects of muscular deconditioning associated with lack of physical activity happen how soon?
in a matter of days if not used
affects on a person when muscle decondition is happening
disuse atrophy
physiological
psychological
social - losing a job
Metabolic changes due to mobility
decreased metabolic rate
altered metabolism of macronutrients
fluid and electrolyte imbalances
gastrointestinal disturbances
calcium loss from bones
respiratory changes
what type of diet should be implemented when a pt is immobile
high protein and calories
what gastrointestinal disturbances occur with immobility
constipation (peristalsis increased with movement)
possible fecal impaction
changes that occur with calcium resorption from bones with immobility
release of calcium into circulation
hypercalcemia may result if kidneys arent functioning appropriately and can affect the heart
what occurs with respiratory changes with immobility
atelectasis
hypostatic pneumonia
if a patient is immobile and having respiratory changes what should you do
turn, cough, deep breathe
Cardiovascular changes with mobility
Orthostatic hypotension – low blood pressure with movement caused by the decreased circulation of fluid and blood
Increased cardiac workload when prolonged periods of immobility
Heart works harder and less efficiently during periods of prolonged rest
Decreased profusion
Thrombus formation
At risk for? Blood clots/pulmonary embolism – can use range of motion to help with profusion
Can start with profusion but lead to respiratory problem
Musculoskeletal changes with mobility
Impairment of musculoskeletal structures, reduced muscle mass
Disuse atrophy
Disuse Osteoporosis
Bone resorption
Calcium leaves the bones and goes into the blood stream/circulation. Bones weak because calcium left bones.
Hypercalciumia occurs because the calcium is now in the blood
Urinary elimination changes with immobility
Recumbent or supine position makes passing of urine difficult
Urinary stasis bacteria grows, increased risk for UTI development
Renal calculi present due to calcium resorption & hypercalcemia – causes kidney stones
Integumentary changes with immobility
Risk for skin breakdown and pressure injuries
Reposition at least every two hours document each time!
Any break in the skin is difficult to heal – protein and calories will help skin heal
Prevention of pressure injuries is key
Psychosocial effects with immobility
Emotional and behavioral responses and changes in coping
Social isolation and loneliness
Every patient responds differently
Safety Guidelines for Nursing Skills
positioning
-determine the amount and type of assistance required for safe positioning determine by pt height and weight
-during positioning raise the side rail on the bed opposite side of where you are
-arrange equipment in the room so it doesnt interfere with the positioning process
-evaluate the patient for correct body alignment and pressure risks after repositioning use pillows
