NURS 203: Unit 10 - Bedside Assessment & Documentation

What to Review for the Health History

- Previous shift report

- Physician orders/diagnosis

- Nursing notes

- Recent blood work

- Diagnostic testing

- Interprofessional notes

- MAR

- Cultural/spiritual considerations

Things to do to Promote Patient Comfort for a Physical Examination

- Explain the process

- Ask for permission

- Pull curtains and warm the room

- Only expose body parts that is being assessed

- Limit position changes

Sequence of Bedside Assessment

1.) General appearance

2.) Measurement

3.) Neurological system

4.) Respiratory system

5.) Cardiovascular system

6.) Skin

7.) Abdomen

8.) Genitourinary system

9.) Activity

(Growing Men Need Really Cool SAGA)

What to Assess for General Appearance in a Bedside Assessment

- Facial expression

- Body position

- Level of consciousness

- Skin colour

- Nutritional status

- Speech

- Hearing

- Personal hygiene

What to Assess for Measurement in a Bedside Assessment

Vital signs

What to Assess for Neurological System in a Bedside Assessment

- Spontaneous eye opening

- Verbal response/speech

- Pupil size and reaction to light

- Lower/upper extremity motor response

- Right/left upper extremity muscle strength

- Right/left lower extremity muscle strength

- Ptosis (drooping)

- Sensation (if indicated)

- Dysphagia

What to Assess for Respiratory System in a Bedside Assessment

- Fitting of any oxygen mask/prong and skin integrity

- FiO2 (fraction of inspired oxygen)

- Respiratory effort

- Shortness of breath

- Breath sounds

- Cough

- Incentive spirometry (if ordered)

What to Assess for Cardiovascular System in a Bedside Assessment

- Rhythm of apical pulse

- Apical/radial pulse comparison

- Heart sounds

- Capillary refill

- Pretibial edema

- Posterior tibial/dorsalis pedis pulse

- Correct IV solution/rate (if there's one)

What to Assess for Skin in a Bedside Assessment

- Colour

- Temperature

- Mobility/turgour

- Skin integrity/lesions/dressings

- IV site condition (if there's one)

- Skin breakdown (Braden Scale)

- Air loss/alternating pressure mattress

What to Assess for Abdomen in a Bedside Assessment

- Contour

- Bowel sounds

- Light palpation of 4 quadrants

- Nausea/vomiting

- Constipation/diarrhea

- Tubes/COCA of drainage/skin integrity/tube integrity

- Stoma/drainage (colour/moisture/bleeding/integrity/COCA)

- Food tolerance/risk of nutrition deficit

What to Assess for Genitourinary System in a Bedside Assessment

- Voiding/catheters

- COCA of urine

- 24 hr fluid balance

What to Assess for Activity in a Bedside Assessment

- HOB at 15 degrees (if bed rest)

- Sitting position/orthostatic hypotension (if ambulatory)

- Any assistance needed

- Need for ambulatory aid/equipment

- Risk for falls/referral to physiotherapy or occupational therapy

- Compression devices (if there's one)

Most Common Critical Findings that Needs to be Reported

- Altered level of consciousness, confusion

- Systolic BP ≤90 or ≥160 mm Hg

- Temperature ≥38°C (100.4°F)

- Heart rate ≤60 or ≥100 bpm

- Respiratory rate ≤10/min or ≥28/min

- Oxygen saturation ≤92%

- Urine output <30 mL/hour for 2 hours

- Dark amber urine or bloody urine (except for urology patients)

- Postoperative nausea or vomiting not relieved with medication

- Surgical pain not controlled with medication; any other unusual pain, such as chest pain

- Bleeding

- Sudden restlessness or anxiety

SBAR

- Situation

- Background

- Assessment

- Recommendation

Situation

- First part of the SBAR that involves stating the situation you are calling about; what's going on?

- Ex.) "I'm concerned about increasing pain and redness at Ms. Seacole's incision site"

Background

- Second part of SBAR that involves providing background information as necessary related to the situation

- Ex.) "Ms. Seacole was admitted for abdominal hernia 2 days ago and is post op day one from abdominal surgery"

Assessment

- Third part of SBAR that involves your assessment of the situation

- Ex.) "Surgical site assessed at 1800 and is clean, dry, and intact, but with a 4 cm redness at the incision cite; pain is currently at 7/10"

Reccomendation

- Fourth part of the SBAR that involves what you think needs to be done

- Ex.) "I think we need to call Ms. Seacole's physician to increase her pain medication"

Change-of-shift reports can be . . .

- Written

- In-person/at bedside

- Huddle

- Audio recording

Do's of Change-of-Shift Reports

- Provide essential background

- Identify nursing diagnoses/health care problems

- Describe objective measurements and observations about patient's condition

- Share significant information about family members as it relates to patient

- Continuously review ongoing discharge plan

- Relay significant changes in the way therapies are given

- Describe instructions given in teaching plan and patient's response

- Evaluate and describe results or nursing or medical care measures

- Be clear about priorities

Don'ts of Change-of-Shift Reports

- Review all routine care procedures

- Review all biographical data available in written form

- Use critical comment's about patient's behaviour

- Make assumptions about relationships between family members

- Wait until discharge to discuss plan

- Describe basic steps of a procedure

- Explain detailed content unless asked for clarification

- Simply describe results as "good" or "poor"

- Force incoming staff to guest what to do first

Transfer Reports

Verbal report exchanged between care providers when a client is moved from one nursing unit or health care setting to another

Telephone Reports

- When a health care provider gives therapeutic orders over the phone to a registered nurse or other health care provider

- Usually occurs at night or during emergencies

- Should only be used when absolutely necessary

Pneumonia

Bacterial infection of the lungs

Pneumothorax

Air in the pleural cavity, which can cause the lungs to collapse

Atelectasis

Collapse of part or all of a lung

Risk Factors for Pneumonia

- Elderly

- Immunocompromised

- Hospitalized

- Post-operative

- Children

Subjective Symptoms to Assess for Pneumonia

- Dyspnea with exertion and at rest

- Fatigue

- Harsh cough with/without phlegm

- Decreased appetite and intake

Objective Signs to Assess for Pneumonia

- Decreased chest expansion

- Guarding

- Decreased breath sounds

- Adventitious breath sounds; fine-medium crackles

- Bronchophony, egophony, whispered pectoriloquy test all positive

Vitals for Pneumonia

- Increased respiratory rate

- Decreased SpO2

- Elevated temperature

Lab/Tests for Pneumonia

- Elevated WBC

- Positive sputum culture (more likely bacteria)

- Chest X-ray

Risk Factors for Stroke

- Diabetes

- Smoking

- Obesity

- Hypertension

- Atrial fibrilation

- History of TIA

Subjective Symptoms to Assess for Stroke

- Symptom onset

- Duration

- Witnesses to the event

- Time of initial medical attention compared with onset of symptoms

- Last seen normal

- Numbness

- Tingling

- SOB

Cardiovascular Assessments for Stroke

- Carotid bruits

- Irregular pulse (arrythmia)

- Hypertension

Neurological Assessments for Stroke

- Altered LOC

- Mental status exam

- Dysphagia

- Dysphasia

- Gait

- Balance

- Strength

- Asymmetry of features and movement

Lab/Tests for Stroke

- CT for confirmation

- BGM to rule out hyperglycemia

Subjective Symptoms to Assess for UTI

- Flank pain

- Frequency

- Urgency

- Dysuria

- Back pain

- Hematuria

- Chills

- Symptom onset

- Interventions

Objective Signs to Assess for UTI

- Cloudy/dark urine

- Foul smelling urine

Genitourinary Assessments for UTI

Bladder distension

Vitals to Assess for UTI

- Elevated temperature

- Elevated pulse and decreased BP (if infection has progressed)

Lab/Tests for UTI

- Elevated WBC

- Presence of nitrates in urine

- Elevated urea nitrogen (if renal system is affected)

- Urine for culture and sensitivity to determine bacteria

Risk Factors for MI

- Family history

- Diabetes

- Smoking

- Obesity

- Hypertension

- Hyperlipidemia

- Inactivity

- Diet

Subjective Symptoms to Assess for MI

- Chest pain

- Dyspnea

- Nausea

- Restlessness

Integumentary Assessments for MI

- Diaphoresis

- Flushed skin

- Pallor (if prolonged)

Cardiovascular Assessments for MI

- Weak peripheral pulse

- Irregular rhythm

- Decreased cap refill

Vitals for MI

- Elevated pulse

- Elevated BP

- Elevated RR

Lab/Tests for MI

- Cardiac enzymes

- Troponin

- EKG

- Cholesterol

Subjective Symptoms to Assess for Diabetes

- Blurred vision

- Reoccurring infections

- Fatigue

Integumentary Assessments for Diabetes

- Delayed wound healing

- Foot injuries

- Reduced hair

growth

- Thin skin

- Pallor at extremities

Cardiovascular Assessments for Diabetes

- Hypertension

- Weak pulses

- Claudication

- Slow cap refill

Neurological Assessments for Diabetes

- Numbness

- Tingling

- Decreased/loss of sensation in limbs

- Vision changes

GI/GU Assessments for Diabetes

- Polyuria

- Polyphagia

- Polydipsia

Risk factors for COPD

- Smoking

- Family history

- Occupational hazards

Subjective Symptoms to Assess for COPD

- Dyspnea

- Decreased activity tolerance

- Productive cough

- Weight loss

Respiratory Assessments for COPD

- Hyper resonance

- Tripod breathing

- Prolonged expiration

- Shallow respirations

- Pursed-lip breathing

- Wheezing/crackles

- Barrel chest

Vitals for COPD

- Increased respiratory rate

- Decreased SpO2 (88-92%)

- Elevated pulse

- Elevated BP

Integumentary Assessments for COPD

- Clubbing

- Cyanosis

Risk Factors for Hypertension

- Smoking

- Dyslipidemia

- Poor diet

- Inadequate exercise

- High BMI

- Diabetes

- Age >60

- Men

- Postmenopausal

- Family history of CV disease

Subjective Symptoms to Assess for Hypertension

- Headache

- Fatigue

- Dizziness

- Vision problems

- SOB

- Sometimes no symptoms

Lab/Tests for Hypertension

- Urinalysis

- Blood chemistry

- Blood cholesterol

- Blood glucose

Vitals for hypertension

- Elevated BP

- Often asymptomatic

Adverse Outcomes of Hypertension

- TIA/stroke

- Coronary artery disease

- Organ dysfunction

- Kidney damage

- Eye damage

Risk Factors of Hypothyroidism

- Autoimmune disease

- Chest radiation

- Thyroid surgery

- History of hyperthyroidism

- Female

- Pregnancy

- Family history of thyroid diseases

Subjective Symptoms to Assess for Hypothyroidism

- Sensitivity to cold

- Constipation

- Dry skin

- Weight gain

- Puffy face

- Hoarse voice

- Coarse hair and skin

- Muscle weakness

- Heavy/irregular menstrual cycles

- Thinning hair

- Depression

- Memory problems

Lab/Tests for Hypothyroidism

- Blood cholesterol

- Blood chemistry

- High TSH

- Low T4

Vitals for Hypothyroidism

- Low BP

- Slow progress of disease

- Bradycardia

- Heart palpations

Adverse Outcomes of Hypothyroidism

- Goiter

- Heart failure

- Dyslipidemia

- Peripheral neuropathy

- Infertility

- Myxedema coma

Risk Factors for Hyperthyroidism

- Autoimmune disease (Grave's disease)

- Overactive thyroid nodules

- Thyroiditis

- Female

- Pregnancy

- Family history of thyroid disease

- Pernicious anemia

- Primary adrenal insufficiency

Subjective Symptoms to Assess for Hyperthyroidism

- Increased hunger

- Nervousness/anxiety/irritability

- Tremor

- Weight loss

- Increased sensitivity to heat

- Changes in bowel patterns

- Coarse hair/skin

- Menstrual irregularities

- Thinning hair

- Sweating

- Tiredness

- Muscle weakness

- Sleep problems

- Warm/moist skin

- Depression

Lab/Tests for Hyperthyroidism

- Blood chemistry

- Low TSH

- High T4

Vitals for Hyperthyroidism

- High BP

- Tachycardia

- Heart palpations

- Arrhythmia

- Overactive reflexes

- Rapid/irregular pulse

Adverse Outcomes of Hyperthyroidism

- Heart failure

- Atrial fibrillation

- Osteoporosis

- Thyroid eye disease

- Thyrotoxic Crisis

Characteristics of Thyroid Eye Disease

- Bulging eyes

- Gritty sensation in eyes

- Eye pressure/pain

- Puffy eyelids

- Inflamed eyes

- Light sensitivity

- Double vision

Characteristics of Thyrotoxic Crisis

- Fever

- Tachycardia

- Nausea

- Vomiting

- Diarrhea

- Dehydration

- Confusion/delirium

Risk Factors for Bell's Palsy

- Unknown

- Viral infections

- Diabetes

- High BP

- Obesity

Subjective Symptoms to Assess for Bell's Palsy

- Weakness to total paralysis on one side of the face

- Pain around the jaw or behind the ear

- Increased sensitivity to sound

- Headache

- Loss of taste

Lab/Tests for Bell's Palsy

- None specific

- Cranial nerve functioning for VII (facial nerve)

Vitals for Bell's Palsy

- Unable to close eye

- Dry eyes

- Drooling

- Normal vital signs

- Facial tissue drooping

Adverse Outcomes for Bell's Palsy

- Irreversible damage

- Partial/complete blindness