nurs 113: assessment pt 1

comprehensive

examination type— interview plus complete head-to-toe examination

focused

examination type— specific problem; system-specific

focused

examination type— limited to one body system

ongoing

examination type— performed as needed to assess status

ongoing

examination type— evaluates client outcomes

assessment, diagnosis, planning, implementation, evaluation

what does ADPIE stand for?

assessment

evaluate the patient’s present data about their health

diagnosis

identify and confirm nursing diagnoses

planning, implementation

initiate clinical decisions based on the patient’s changing health status

evaluate

determine outcomes of care

focused

examination type— evaluate an intervention

observing

data collection method— signs of clinical distress

observing

data collection method— behavioral health

observing

data collection method— environment

interviewing

data collection method— health history

examining

data collection method— head to toe physical

behavioral health

psychological presence

environment

safety concerns, presence of others

airway, breathing, circulation, cognition

signs of clinical distress

airway, breathing

concept: oxygenation

airway

grasping at throat

airway

wheezing or stridor noises

airway

frothy sputum

airway

sudden or violent coughing

airway

coughing up blood

breathing

apnea

breathing

dyspnea

<12 or >20

respiration rate per minute symbolic of inadequate breathing

dyspnea

use of accessory muscles

dyspnea, circulation

cyanosis

dyspnea

nasoflaring

dyspnea

difficulty breathing

dyspnea

grunting

circulation

concept: perfusion

circulation

ashen

circulation

pallor

circulation

diaphoretic

diaphoretic

perspiring

circulation

pain

cognition

concept: intra-cranial regulation

cognition

awake-alert-responsive

cognition

oriented to person-place-time situation

cognition

change in level of consciousness

level of consciousness

LOC

cognition

disoriented to person-place-time situation

cephalo-caudal

head-to-toe approach

objective physical examination data

be prepared, be systematic and orderly, assess each body system, look for symmetry and equality, critically investigate and evaluate findings, assess present state of health, adhere to professional obligations

professional obligations

national guidelines, evidence-based practice, standard precautions, screenings

inspection

continually observe for symmetry-equality-congruence

inspection

observe shape, size, color, position, edema, moisture, pulsation

inspection

observe facial expressions

inspection

palpation

palpation

palmar surface (finger pads)

palpation

assess temperature, texture, moisture, landmarks, abnormalities

palpation

clean, warm hands, short fingernails

abdomen

palpate before auscultating except

abdomen

auscultate before palpating

1-2 cm

abdomen palpation depth

circular

motion in which to palpate abdomen

light, intermittent

pressure with which to palpate abdomen

auscultation

sense of hearing

auscultation

first learn normal sounds before identifying abnormal or extraneous sounds

auscultation

requires a good stethoscope

auscultation

requires concentration and practice

percussion

tapping your fingers

percussion

sound determines location, size, and density of underlying structures

percussion

assessment of abdomen and lungs

inspection, palpation

concept: tissue integrity

inspection, palpation

consists of skin, hair, nails

color

make sure it is uniform

pink

mucous membrane color

cyanosis

deoxygenated hemoglobin (Hgb)

cyanosis

light-skinned— dusky blue

cyanosis

dark-skinned— looks ashen-gray especially on lips, tongue

cyanosis

fingers, nail beds, lips, mucous membranes, earlobes, palmar and plantar surfaces

pallor

decreased blood flow, decreased number of RBCs, sudden drop in BP

pallor

pale cast to skin, mm, lips, nail beds

pallor

dark-skinned— ashen-gray, gray lips

jaundice

increased serum bilirubin, liver or hemolytic disease

jaundice

yellow

jaundice

green to orange tint

jaundice

light-skinned— skin, sclera, mm, nails, palms, soles

jaundice

dark-skinned— hard palate

erythema, hyperemia

dilated superficial blood vessels

erythema, hyperemia

febrile states, inflammation, excessive alcohol intake, abnormal redness

fever

febrile states

vascularity, bleeding, ecchymosis

bleeding from IV sites, mucous membranes, lesions

vascularity, bleeding, ecchymosis

clotting disorders, trauma, medication side effects, anticoagulants

older adult

may bruise more easily

older adult

normal skin changes— senile lentigo, pallor without anemia, cherry angioma, skin tags

IV drug abuse

IVDA

IVDA track marks

darker pigmentation, follows veins, sublingual; groin

body art, piercing

document brief description and location

diaphoresis

lysis of a fever, increased basal metabolic rate

basal metabolic rate

BMR

cool/clammy skin

sudden drop in BP

turgor

elasticity and hydration

turgor

supple/sluggish

turgor

where to examine: trunk/clavicle

edema

pitting, non-pitting, dependent, generalized, peritoneal space