NUR104 - Module 1 - Assessment

130-139/80-89

Stage 1 hypertension

greater than or equal to 140 / greater than or equal to 90

Stage 2 hypertension

inspection, auscultation, percussion, and palpation

What are the steps of an assessment?

CN V (trigeminal)

• assess the face for strength and sensation

• ask the client to clench their teeth while palpating the muscles

• Which cranial nerve is being assessed?

CN VII (facial)

• assess the face for symmetrical movement

• have the client smile, frown, puff up their cheeks, raise their eyebrows, close their eyes, and show their teeth

• which cranial nerve is being assessed?

CN XI (spinal accessory)

• assess the head and shoulders for strength

• place your hands on your client’s shoulders and ask them to shrug their shoulders; then turn the head against the resistance of your hand

• which cranial nerve is being assessed?

Nursing Process

Steps include:

1. assessment

2. analysis

3. planning

4. implementation

5. evaluation

ISBARR

• Identify. State the team member’s name and title.

• Situation. Provide the circumstances that have required the communication to occur.

• Background. Provide the background data regarding the client to assist the provider with familiarity.

• Assessment. Provide the most recent set of vital signs or other data relevant to the communication.

• Recommendations. Provide any suggestions that may be helpful to the situation.

• Read back orders. Repeat the orders that are given and clarify anything that is unclear.

inspect, auscultate, percuss, and palpate

What is the examination sequence for the abdomen?