X Foundations - Chpt 5 - Assessment Flashcards
Order of Priority - ABC
- Airway
- Breathing
- Circulation
The first step in the nursing process
Assessment
Purpose of physical assessment
- evaluate current phys condition
- detect early signs of health prob
- establish BASELINE for future comparison
- evaluate clients response to treatment
The first admission assessment done by
RN
4 assessment technicques
- Inspection (with eyes)
- Percussion (lightly w fingertips, tapping, usually docs)
- Palpation (light touch. Deep palpation usually docs)
- Auscultation (stethoscope)
PERRLA
Pupils, Equal, Round, Reactive to Light, Accommodation
use pen light to assess
COPD
Chronic Obstructive Pulmonary Disease
Sounds of heart indicated by
S1, S2 (lub, dub)
normal bowels sounds
8-30 gurgles p/minute
Borborygmus
abnormal bowel/abdomen sounds
If claiming bowel sounds absent, how do you confirm
listen for 1 minute per quadrant (4 min)
Equipment needed for Physical Assessment
- tongue depressor
- pen light
- pen/paper
- stethoscope
- Spygmonometer
- watch w second hand
- thermometer
- scale
- Snellen chart (eye )
- Wong-Baker chart (faces, objectify pain)
Approaches for collecting data
- head to toe approach
- body systems approach
A&O x 3
Alert and Oriented ( 1.Person, 2.Place, 3.Time)
Where do you perform skin turgor test?
under clavicle. look for skin tenting (when skin stays up after you pinch it)
Lung Sounds
- Trachael
- Bronchial (main stem bronchi)
- Bronchovesicular (tubes and alveoli)
- Vesicular (margin of lungs, Alveoli)
Adventitious Lung Sounds
other than clear sounds
- crackles (fluid in alveoli)
- Gurgles (wet, noisy)
- Wheezes
- Rubs (pleura rubbing, leather creaking)
Capillary refill
press on nail bed, blood should return in under 3 sec.
Brawny/Turgid Edema
so swollen, you can’t even push it in
Weeping Edema
when the interstitial fluid seeps out of pores.
