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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.