Nursing and Patient Assessment

Protecting Patient Privacy

• HIPAA Basics
  • Only healthcare providers directly caring for the patient can access patient charts.
  • Access is on a "need-to-know" basis only.
  • Family and friends cannot access information without patient consent.
  • Always log off and close charts/computers when done.
  • Discuss patient information only with permission.

SBAR Communication Protocol

• SBAR: Standardized method to convey essential information.
  • Situation: Current issue (e.g., patient experiencing chest pain).
  • Background: Relevant history (e.g., admitted with pneumonia).
  • Assessment: Clinical observations (e.g., diminished lung sounds, O2 at 88%).
  • Recommendation: Suggested actions (e.g., increase oxygen).

Immediate vs. Non-Urgent Situations

• Immediate Action Needed:

  • Chest pain
  • Trouble breathing
  • Sudden confusion (may indicate a stroke)
  • Unstoppable bleeding
  • Seizures
  • High fever in infants
  • Allergic reactions

• Can Hold Briefly:

  • Decreased skin elasticity
  • Delayed wound healing
  • Memory changes (assess for dementia/delirium)
  • Risk of elder abuse (look for bruises, poor hygiene).

Dementia vs. Delirium

• Dementia
  • Slow onset, typically irreversible (e.g., Alzheimer's)
  • Long-term duration
  • Clear consciousness
• Delirium
  • Sudden onset, often due to toxins
  • Potential for full resolution once the cause is treated

Cranial Nerve Assessment

• Cranial Nerves: Know each nerve's function and assessment method.

1. Olfactory: Smell, assess with coffee/vanilla.
2. Optic: Vision, assess visual acuity via Snellen chart.
3. Oculomotor: Eye movement, check PERRLA with penlight.
4. Trochlear: Eye movement down and inward.
5. Trigeminal: Face sensation & chewing, assess with cotton ball/teeth clenching.
6. Abducens: Lateral eye movement.
7. Facial: Facial expressions & taste, assess by asking for expressions.
8. Acoustic/Vestibulocochlear: Hearing & balance, assess using whisper/tuning fork.
9. Glossopharyngeal: Taste & gag reflex, assess by saying “ah”.
10. Vagus: Swallowing & voice, assess by listening to voice.
11. Spinal Accessory: Shoulder & neck movement.
12. Hypoglossal: Tongue movements, assess by asking to stick out tongue.

Seizure Assessment Techniques

• If conscious: Ask about previous seizures, frequency, trigger factors, and postictal symptoms.
• If unconscious: Obtain description from witnesses about body movements, color changes, incontinence, and duration.

Understanding Rigidity Types

• Decorticate Rigidity:
  • Arms pulled to core = upper flexion (caused by cerebral cortex damage)
• Decerebrate Rigidity:
  • Arms extended = lower and upper stiffness (more severe; caused by brainstem damage)

Nutritional Assessment and Abdominal Assessment

• Abdominal Quadrants: Know the organs and their locations within each quadrant (RUQ, LUQ, RLQ, LLQ).

  • Use palpation and percussion techniques appropriately.

• GERD Symptoms: Heartburn, regurgitation (food/acid), and dysphagia.

• Bowel Sounds: Auscultate first, assess for hyperactive (increased motility - e.g., diarrhea) or hypoactive (slow or absent - post-surgery).

Dermatological Considerations

• Normal vs. Concerning Skin Conditions: Utilize ABCDEF rule for mole assessment (Asymmetry, Border, Color, Diameter, Elevation/Evolution, Funny looking).
• Melanin: Natural pigment offering UV protection; more melanin means lower skin cancer risk.

Nail Assessment

• Normal Nail Angle:
  • Normal: 160 degrees
  • Clubbing indicates chronic hypoxia (e.g., >180 degrees).

Skin Conditions and Their Assessment

• Recognize conditions like Petechiae, Purpura, Xerosis, and Cyanosis.

  • Examine rashes focusing on provocation, quality, region, severity, timing, and impact on life.

• Skin in different age groups:

  • Infants may show Mongolian spots; adolescents typically have acne; older adults show signs of aging like xerosis and senile purpura.