Exam 4

When is it appropriate to perform a braden scale assessment?

• Upon admission and

  • Acute care - on a defined schedule + whenever there is a change in condition

  • Critical care - every 24 hours

  • Long-term care - weekly for 4 weeks after admission, then quarterly and when there is a change in condition

  • Home care - every RN visit

When is it appropriate to perform a fall risk assessment?

• upon admission

• every shift change

• when there is a change in pt condition

• after a fall

What assessments are necessary to follow up with when a pt has abnormal vitals?

• low bp/hr - check for mental status, blurred vision diziness, cool/clammy/hot skin

• Temperature - assess skin feeling, diaphoresis, shivering

• Oxygen Sat - Mental status, lung sounds

what to do when pt has abnormal vital signs?

• Have another RN/provider recheck vitals

• Check for faulty equipment/size of equipment

• Report to charge nurse/provider, document findings

Components of OLD CARTS

• Onset

  • When did it start? Was it gradual/abrupt? Is it a returning pain?

• Location

  • Where is the pain? What body part is it on? Where on the body part is it?

• Duration

  • How long has it been going on? how long does it last?

• Characteristic

  • What kind of pain is it? Burning, aching, sharp, or dull?

• Alleviating/Aggravating

  • What makes it worse? What makes it better?

• Radiating/Relieving

  • Does anything cause it to spread? Does anything Make it better?

• Timing

  • When does it usually come on? Is it constant or on and off?

• Severity

  • if 0 was no pain, and 10 was the worst pain in the world, what would you rate it?

How to identify normal vs abnormal cardiac-heart rhythms

Listen for interval between S1 and S2, as well as S2 and then next S1

Normal Heart rhythms

• regular interval of times between each heartbeat (S1+S2=1HB)

• Short, regular pause between S1 and S2

• Predictable beats

• Between 60-100bpm

Abnormal Heart rhythms

• Heart fails to beat on a regular+constant rhythm

• Intervals are interrupted by early, late, or missed beats

• Unpredictable beats, or overly fast/slow

• BPM below 50, above 100

• May have extra heart sounds

Extra Heart sounds

• Heart murmur

  • whooshing sounds: blood flowing thru chambers (wall defect) or valves (narrowing/regurgitation - valve not fully shutting)

• S3

  • after S2

  • put pt on left side and use bell

  • Lub-dub-tuh

  • Fluid value overload/HF

• S4

  • before S1

  • Tuh-lub-dub

  • atria struggling to get blood into resistant ventricles

How to Identify lung sounds

• Check 2 points on pts chest and 7 points on pt back, have pt breathe in and out every time you place the stethoscope

Normal lung sounds

• vesicular

  • soft, breezy, low pitched

  • inspiratory phase 3x longer than expiratory phase

• Bronchovesicular

  • Blowing sounds that are medium-pitched and of medium intensity

  • inspiratory and expiratory phase are equal

Adventitious Sounds

• Crackles - during inspiration

  • Fine - High-pitched, fine, short, interrupted crackling sounds

  • Medium - lower, moister sounds

  • Coarse - Loud, bubbly sounds

• Ronchi

  • loud, low pitched rumbling

  • insp/exp

• Wheezes

  • high-pitched, continuous musical sounds during insp/exp

• Pleural Friction Rub - dry, rubbing, grating sounds during insp/exp

Muscle Strength grading

• Grade 0 - 0%

  • No evidence of contractility

• Grade 1 - 10%

  • Slight contractility, no movement

• Grade 2 - 25%

  • Full ROM, gravity eliminated

• Grade 3 - 50%

  • Full ROM with gravity

• Grade 4 - 75%

  • Full ROM against gravity, some resistence

• Grade 5 - 100%

  • Full ROM against gravity, full resistence

Grading of Pulses

• Bilateral = on both sides

• 0 - pulse absent

• 1 - diminished/barely palpable

• 2 - normal/expected

• 3 - full/strong

• 4 - bounding pulse

Grading of Edema

• Press down firmly w/thumb on edematous area for several seconds, then release

• Depth of pitting determines edema degree

  • 1+ - 2 mm

  • 2+ - 4mm

  • 3+ - 6mm

  • 4+ - 8mm

Normal findings for extremities: Capillary refill, pulses, color, temp

• cap refill should be less than 3 seconds

• pulses should be +2 bilaterally

• Color depends on skin tone

  • light - ivory to ruddy pink

  • dark - light brown to deep brown

  • Can be altered by room temp

• Temp should be warm, can vary in degree of warmth throughout body

Abnormal Pigmentations of skin

• Bluish tint - cyanosis

• Pallor - decrease in color (no pink is where pink should be)

• Vitiligo - patchy loss of pigment

• Jaundice - Yellow-orange

• Red - erythema

Normal findings of abdominal assessment: Inspection

• Skin

  • Skin color should be similar to the rest of the body

  • faint venous patterns in thin pts

• Umbilicus

  • Flat/concave

  • color similar to surrounding skin

• Contour/Sym

  • Flat/round/concave - if symmetrical

  • smooth, symmetrical contour

  • older adults have increased distrib of fat

• Movement

  • men breathe abdominally

  • women breathe costally

  • Peristaltic movement/aortic pulsations may be visible in thin pt

Normal findings for abdominal assessment: Auscultation

• Bowel Motility

  • gurgling/clicking sounds occuring btwn 5-35 times per min

  • 5-20 seconds to hear a sound

Normal Findings for abdominal assessment: Palpation

• smooth with consistent softness

• guarding/muscle tenseness can occur while palpating a sensitive area

Expected findings: Urine

• Normal output range is 1-2L/day

  • most people void 5+ time a day

• Color should be anywhere from pale straw to amber

• Urine should be transparent

  • becomes cloudy if left standing

  • may appear cloudy if urinated early in the morning

• Should smell like ammonia

Expected findings: Bowel movements

• color for infants should be yellow, brown for adults

• Malodorous odor

• Soft and formed, resembles diameter of rectum

• Should occur daily to 3 times a week