Hospitalized Patients

a device that delivers supplemental oxygen through small prongs inserted into the nostrils

nasal cannula

What is added to assessment when patient has a nasal cannula? (5)

assess O2 flow rate, ensure placement, check for skin breakdown, assess resp status, and O2 sat.

A device that covers the nose and mouth to deliver higher concentrations of O2

oxygen mask

What is added to the assessment when patient has Oxygen Mask? (6)

assess fit, monitor irritation, ensure proper flow, check for obstruction, assess resp effort, and assess O2 sat

A surgical opening in the trachea that allows direct airway access through a tube

tracheostomy

What is added to assessment when patient has a tracheostomy? (4)

assess stoma, check placement of tube, monitor resp effort, ensure suction and humidification as ordered

a tube inserted into the pleural space to remove air, blood, or fluid and re-expand the lung

chest tube

What is added to the assessment when patient has a chest tube? (5)

assess insertion site, assess dressing, assess output amount, ensure tubing isn’t kinked, and monitor resp status

A tube passed through the nose into the stomach for feeding, decompression, or medication delivery

nasogastric tube

What is added to assessment when patient has an NG tube? (6)

assess placement, check patency, monitor skin irritation, assess abdominal distension, nausea and aspiration risk

A tube inserted through the abdominal wall into the stomach for ong-term feeding

Gastronomy Tube

What is added to assessment when patient has a G tube? (4)

assess stoma, verify tube placement, monitor residuals and tolerance of feedings, and ensure clean dry site

A surgically created opening for elimination of stool or urine through the abdominal wall

ostomy

What additional assessments are done when patient has an ostomy? (5)

assess color and moisture, check surrounding skin, measure and document output, ensure pouch is intact, ensure patch is emptied regularly

rigid protective device used to immobilize bones and promote healing after a fracture or surgery

cast

What additional assessments are done when patient has a cast? (8)

assess circulation, movement, sensation, check for swelling, pain, odor, ensure edges are smooth, and skin is protected

A metal device with rods and pins placed outside the body to stabalize a bone or fracture

external fixator

What additional assessments are done for patients with an external fixator? (4)

assess pin sites, ensure frame stability, perform pin care, and monitor neurovascular status

The location where an IV catheter is inserted into a vein for fluid or medication delivery

Intravenous infusion site

What additional assessments are done for patients with an IV? (4)

inspect site, palpate warmth and tenderness, verify correct solution and rate, and monitor signs of infiltration or phlebitis

A cut made during surgfery to access internal structures

surgical incision

What additional assessments are done for patients with surgical incisions? (7)

assess approximation of edges, presence of drainage, redness, swelling, tenderness, monitor dressing, and change dressing

A break in the skin surface exposing underlying tissue

open wound

What additional assessments are done for patients with open wounds? (7)

assess size, drainage, odor, surrounding skin, swelling, tenderness, and change and monitor dressing

A surgical wound that has become contaminated with pathogens showing signs of infection

infected incision

What additional assessments are done for patients with infected incisions? (10)

assess for size, temp, swelling, purulent drainage, odor, inc. pain, monitor temp, WBC count, notify provider, and follow wound care orders

What 7 additional assessments are done for a patient with a wound drain?

insertion site, type, function, output, dressing, and pain

What are 9 additional assessments for a patient who is unconcious?

airway and breathing, glasgow scale, pupil response, motor response, protective reflexes, skin integrity, turn, incontinence check, and safety

What are the 3 main parts of the Glasgow Coma Scale?

eye opening, verbal response, and motor response

A low score on the Glasgow Scale indicates…

worse neurological status

When patient does not respond to voice use…

painful stimuli techniques

What are the 5 painful stimuli techniques?

nail plate pressure, trapezius muscle pinch, supraorbital pressure, mandibular pressure, and sternal rub

Sternal Rub

• use knuckles to rub firmly on sternum in a circle

• Look For: ________, __________, __________ vs. posturing

grimace, movement, withdrawal

Mandibular Pressure

• press behind jaw at mandible angle

• very painful

• look foor: ______ movement, _________, and arms _________ up/localized.

jaw, grimace, reaching

Supraorbital Pressure

• press up under bony ridge above the eye with thumb

• avoid in patients with facial trauma

• Look for: _______, eye __________, and __________ hand movement

grimace, opening, localizing

Trapezius Muscle Pinch

• grasp trapezius between fingers and twist/pinch

• Look for: ________, pulling _______, ___________ the pain, and ____________.

grimace, away, localizing, posturing

Nail Plate Pressure

• use pen or knuckle to press firmly on nailbed

• Look for: purposeful ________ (good), abnormal ____________ (bad), and no response (worst)

withdrawal, posturing,