Nursing Assessment: Process, Documentation, General Survey, and Vital Signs
Reassignment: Case Study Assignment
Task: Complete a case study on a sick individual.
Data Collection: Read the case carefully and collect all relevant data by asking every possible question.
Table Usage: Utilize a provided table, adding more columns as needed for comprehensive data collection.
Categories for Questions:
Current Illness: Ask all possible questions related to the patient's current symptoms, such as when symptoms first occurred (e.g., fever, chills, headache), what makes them worse, and what makes them better.
Personal Health History.
Lifestyle and Health Practices.
Cultural or Spiritual Beliefs: Inquire about any beliefs that could affect the person's care.
Question Quantity: Essential to ask many questions; submitting only two questions per column will indicate inadequate effort, especially since many example questions are available in the course material.
Resources: Leverage lecture content, assigned book, and Google for additional questions.
Submission: Hand in the assignment via dropboxes located in either the main course or the discussion courses. It is accessible under assignments in the discussion section (e.g., Discussion one).
Deadline: Due on a Wednesday in November.
Work Format: Students can work individually, in partners, or in groups.
Class Schedule and Punctuality
Class Times: Classes start at 1:00 PM and 2:30 PM.
Lateness Policy: Significant lateness without a valid excuse is not acceptable. Punctuality is important as it respects the time of guest speakers (like Mrs. Haas) and the instructor.
Physical Assessment Tutors
Available Tutors: Anthony and Gabrielle are available as tutors for physical assessment.
Access to Course Material: Similar to previous tutors, they have access to the course content and are aware of the learning objectives and exam expectations.
Instructor Communication: The instructor will inform the tutors about current class topics.
Recommendation: Students are highly encouraged to utilize this resource. If in-person meetings are not possible, reach out to the tutors to arrange a Zoom session.
Attendance Tracking: Tutors will report student attendance.
Review of Previous Topics
Covered Material: Introduction to the nursing process, practice questions, health history, interviewing techniques, communication styles, and essential questions to ask.
Lab Work: Students have been actively practicing physical assessment techniques in the lab, including palpation, percussion, and auscultation.
Rechecking Data
Process: After interviewing the client and conducting an assessment, nurses must review all gathered data.
Data Sources: This includes subjective information from the patient, objective data from vital signs and observations, and findings from the physical assessment.
Clarification: If any confusion or lack of clarity exists, nurses must ask more questions.
Verification: If a finding is uncertain (e.g., suspected heart murmur), verify it with another healthcare professional.
Comparison: Compare subjective data (patient's statements) with objective data (assessment findings).
Example: If a patient reports severe pain, vital signs (heart rate, blood pressure, respirations) should typically show an increase. If the vitals do not reflect this, further investigation is needed.
Goal: Ensure all data aligns and no further questions remain.
Documentation
Fundamental Rule: "If we don't document it, we didn't do it." All data and actions must be thoroughly documented.
Systems: Use either an Electronic Health Record (EHR) or Electronic Medical Record (EMR), which are interchangeable terms for the patient chart.
Content: Documentation must include both subjective and objective data.
Guidelines: Specific documentation guidelines and assessment forms vary by hospital and hospital system.
Becoming an Expert Nurse: Critical Thinking and Professional Growth
Open Mind: Always maintain an open mind during assessments and avoid making assumptions about patients.
Rationality: Ensure that all gathered information and formed opinions are rational and make sense.
Reflection: Reflect on all collected data before drawing conclusions.
Experience: Utilize past experiences to build knowledge. While students may have limited experience initially, it will continuously grow throughout their careers, leading to quicker assessments and better problem recognition over time (e.g., a two-minute assessment after years of experience).
Knowledge Base: Continuously acquire and build an adequate knowledge base relevant to nursing practice.
Interactions: Be aware of interactions between the patient and others (e.g., spouse, family, friends). Observe for supportive, controlling, or culturally influenced behaviors.
Environment: Be mindful of the assessment environment. Ensure patient privacy by closing doors during discussions and examinations.
Practice Questions
Question 1: What should the nurse do before meeting a patient for the first time?
Answer: Review the patient's chart.
Question 2: A patient enters the ER with a heart rate of 40 beats per minute. What assessment would the nurse complete?
Answer: Emergency assessment.
General Survey
Definition: The general survey is the initial, purely observational part of a physical examination, conducted when first seeing the patient before any direct interaction.
Initial Observations (Purely Observational):
Appropriateness of dress for the weather.
Appearance: disheveled/unkempt vs. clean.
Odor (body odor, breath odor).
Components of General Survey (with Interaction/Closer Observation):
Physical Development: Assess if development is consistent with the patient's age and gender.
Body Build: Note if the patient appears overweight, underweight, or of normal build.
Gender and Age.
Skin Condition and Color: Observe for normal pink or flesh tones, and identify any abnormal variations like yellowing (jaundice) or purple/blue discoloration (cyanosis).
Dress and Hygiene: Assess clothing and overall body hygiene.
Posture and Gait: Note if the patient is sitting straight or slumped. Observe their walk (gait) for steadiness, limping, or guarding of any body parts.
Level of Consciousness (LOC): Should ideally be awake and oriented imes 4 (person, place, time, situation/event). For example, ask who the president is, what holiday is coming, what season it is, and what brought them to the clinic.
Body Movements and Behaviors: Observe for sporadic movements, guarding, lashing out, or calm demeanor.
Expression and Speech: Assess for clear speech versus slurring or difficulty understanding. Observe facial expressions for pain (wincing), calmness, smiling, or blank stares.
Vital Signs: Note if vital signs are normal or abnormal.
Vital Signs: Essential Indicators
Significance: Vital signs are a crucial step in the assessment process, providing vital clues about the body's physiological state.
Memorization: Normal vital sign ranges must be known by nurses for their entire career.
Temperature
Average: 98.6^ ext{o}F (can be slightly lower or higher).
Measurement Sites: Oral, rectal (most accurate, used when necessary), temporal.
Temporal thermometer readings can vary by m{1^ ext{o}F} higher or lower but should generally align with other sites.
Hypothermia: Below 96^ ext{o}F .
Hyperthermia/Fever: Above 100^ ext{o}F .
Pulse
Normal Range: 60-100 beats per minute.
Physiology: Occurs when the heart contracts, pumping blood from the ventricles to the aorta, creating a shock wave that travels along and creates arterial (peripheral) pulses.
Measurement Sites: Apical (auscultated with a stethoscope) or radial (palpated at the wrist near the thumb).
Key Pulse Points (Head to Toe): Temporal, Carotid (important to assess one side at a time to prevent reducing cerebral blood flow), Brachial, Radial.
Respirations
Normal Range: 12-20 breaths per minute.
Assessment Technique: To obtain an accurate reading without the patient consciously altering their breathing:
Palpate the radial pulse for 30 seconds and multiply by 2 .
Immediately after, while still appearing to take the pulse, observe the rise and fall of the patient's chest for another 30 seconds.
Multiply the observed respiratory rate by 2 .
Observation: Assess the character of breaths (shallow, deep, concave, struggling).
Blood Pressure
Definition: Reflects the pressure exerted on the walls of the arteries.
Variability: Changes with the cardiac cycle and throughout the day (e.g., higher during exercise, lower at rest, unless influenced by strong emotions).
Systolic Pressure: The top number (e.g., 120 in 120/80 ).
Occurs when the ventricles contract.
Corresponds to the first loud sound heard during auscultation.
Diastolic Pressure: The bottom number (e.g., 80 in 120/80 ).
Occurs when the ventricles relax.
Corresponds to the last sound heard before silence.
Normal Range: 120/80 or lower.
Position Changes: Blood pressure varies related to changes in position. Rapid changes can cause dizziness (orthostatic hypotension), especially in older adults. Advise patients to rise slowly (from lying to sitting to standing).
Pulse Pressure: The numerical difference between the systolic and diastolic blood pressure values.
Pain (The Fifth Vital Sign)
Measurement: Assessed on a scale of 0-10 for adults.
Scale Interpretation: 0 represents no pain at all, while 10 signifies the worst pain ever felt.