NUR-2300__Exam_1_Review

Page 1: Physical Assessment Techniques

Techniques of Assessment
- Inspection: Observing the patient visually for any signs of abnormalities.
- Auscultation: Listening to body sounds (e.g., heart, lungs, and bowel sounds).
- Palpation: Using hands to feel the body for organs and abnormalities.
- Percussion: Tapping on body parts to check for sounds indicating different conditions.
Patient Education Techniques
- NG Tube: Educate the patient about the procedure; if applicable, teach self-care for feeding and cleaning.
- Foley Catheter: Inform the patient of possible burning or pain during first urination post-removal.
Abdominal Assessment
- Objective Data: Collect vital signs.
- Subjective Data: Gather information from the patient about their symptoms.
- Assess through inspection, auscultation, palpation, and percussion.
- Conduct tests like checking for bowel sounds (6-20 per minute) and measuring stomach pH (normal around 4.5).
- Consider the shape of the abdomen and identify abnormalities using visual diagrams.

Bowel Elimination
- Normal Bowel Habits:
  - Frequency: Typically 1-3 times/day to every other day.
  - Consistency: Soft, formed, easy to pass.
- Abnormal Bowel Habits:
  - Frequency: Diarrhea indicates frequent loose stools; constipation indicates less than 3 bowel movements per week.
  - Consistency: Hard, lumpy stools for constipation; watery stools for diarrhea.

Stool Characteristics:
- Color:
  - Brown: Normal.
  - Black/tarry: Indicates possible GI bleeding.
  - Pale/clay: Biliary issues.
  - Red: Lower GI bleed.
  - Green: Indicates infection.
- Odor:
  - Mild to strong (depends on diet); foul-smelling may indicate infection or malabsorption.
- Shape:
  - Cylindrical and smooth is normal; thin/ribbon-like may suggest obstruction, pencil-thin could indicate narrowed colon.
- Symptoms:
  - Normal: No pain or straining.
  - Abnormal: Bloating, cramping, urgency, incomplete emptying, blood/mucus.
Assessment Steps:
1. Subjective Data: Ask about habits, changes, pain, and diet.
2. Objective Data:
- Inspect: Check for distension, scars, visible peristalsis.
- Auscultate: Listen for bowel sounds.
- Palpate: Evaluate softness, firmness, tenderness, or masses.
- Percuss: Note tympany vs. dullness.
Nursing Care for Issues:
- Constipation: Increase fiber, ensure hydration, promote activity, and establish a bowel routine.
- Diarrhea: Monitor hydration, recommend small meals (BRAT diet), and administer anti-diarrheals if needed.
- Incontinence: Maintain skin integrity with barriers, implement scheduled toileting, assess causes.

Healthy Bowel Habits:
- High-fiber foods, adequate water intake, regular exercise.
- Monitor for signs to seek help, such as persistent changes or pain.
Enemas Definition:
- Used to promote bowel movements, relieve constipation or clear the bowel before procedures.
- Types & Indications:
  - Cleansing Enema: Stimulates evacuation.
  - Retention Enema: Softens stools.
  - Medicated Enema: Delivers medication.
  - Carminative Enema: Relieves gas.
Administration Steps:
1. Gather Supplies: Enema bag, lubricant, etc.
2. Position Patient: Left Sims' position.
3. Prepare and administer the enema, encouraging retention.
4. Assist with elimination and assess outcomes (document stool characteristics).

NG Tube Purpose:
- Stomach Decompression: Removes fluids/air for various medical situations.
- Nutritional Support: Provides nutritional supplements when oral intake is not possible.
- Medication Administration: Allows direct delivery to the stomach.
Troubleshooting:
- Address issues such as clogged tubes or displacement by checking placement and monitoring for discomfort.
Patient Education:
- Teach patients about the tube purpose, adverse effects, and importance of head elevation during feeding.
Nursing Care:
1. Verify placement regularly.
2. Maintain tube patency by flushing.
3. Monitor for complications like irritation or aspiration signs.

G-Tube Purpose:
- Long-term nutritional support and medication administration.
- Provides necessary nutrition for patients unable to meet needs orally.
Care Assessment:
- Regular checks for placement, irritation, and pain.
- Ensure tube patency with flushing.
Patient Education:
- Care techniques for the tube and stoma, signs of infection, and importance of routine check-ups.

Hygiene:
- Daily cleaning with soap and water, monitoring for skin breakdown.
Nutritional Management:
- Administer tube feedings as directed, and monitor for intolerance signs.
BMI & Nutritional Assessment:
- BMI calculations, nutritional definitions are based on weight and height metrics.

Nutritional Status
- Assess through history, measurements (like BMI), laboratory values, physical exams, and functional capacity.
Definitions:
- Undernutrition: Insufficient intake leading to health issues.
- Overnutrition: Excessive intake causing obesity.
- Malnutrition: Imbalance of nutrients affecting health.

Older Adults:
- Address metabolism slowdown, sensory decline, decreased saliva, and absorption issues.
- Recommendations include balanced diets, hydration, protein intake, and light exercise.

Inspection Techniques:
- Observe for symmetry, movement, scars, and distension.
Auscultation Findings:
- Normal bowel sounds should indicate function with variations noted during examination.
Palpation & Percussion:
- Assess for tenderness and organ sizes or abnormalities in sound corresponding with fluid presence.

Quadrants:
- RUQ: Liver, kidney, gallbladder.
- LUQ: Spleen, stomach, pancreas.
- RLQ: Appendix, right ovary.
- LLQ: Left ovary, descending colon.
- Midline: Aorta, bladder.