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Types of Assessments:
Comprehensive, Ongoing, Focused, Emergency
- Comprehensive: everything
- Ongoing: beginning of shift
- Focused: only assess for specific problem
- Emergency: ABCs
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Purpose of Assessment
- gather baseline data
- Holistic Foundation of Nursing Process
- data confirmation: affirm data is correct
- guides the nursing process
- clinical judgements
- evaluate
- identify risk factors for alterations in health
- screen for risk factors/warning signs of cancer
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Guideline for Health Hx
- 1. Biographical Data
- 2. Reason for Seeking HC: focuses rest of assmt, open-ended q's, document in pt's own words
- 3. Hx of Present Health Condition: explore thoroughly
- 4. Medical Hx: may give insight to present symptoms, ID risk factors (past illnesses), chronic heal probs/treatment
- 5. Family Hx: consider disorders w/genetic links, risk factors
- 6. Lifestyle: contributes to overal health and well-being
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Prepare the Patient:
- sensitive to psychological and physiological needs
- Explain: first will be question, second will be physical exam (not painful)
- Use general terms
- Explain in more detail during procedure
- Direct & Honest
- Modesty
- Empty bladder?
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Prepare the Environment
- adequat lighting
- exam table
- gown and drape
- instruments/supplies
- warm enough?
- curtain/screen if needed
- infxn control
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Systematic Manner of Assessment
- Systematic and Consistent Examination
- Head to Toe or Body Systems
- know what you need to check, know every time
- check for symmetry
- regulate/pace the assmnt appropriate to pt situation
- minimize movents of person (organized order, logial flow)
- use correct terminology in chart but general terms w/pt
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Skin/Older Adult:
Senile Keratosis
raised dark areas
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Senile Lentigines
flat brown age spots
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Cherry Angioma
small round red spots
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Skin/Infant-Child:
Milia
"whiteheads"
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Lanugo
fine, downy hair in first two weeks of infancy
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Adventitious Breath Sounds
not normally head in lungs but can be heard when aucultated with normal sounds
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Auscultation
listen w/stethoscope to sounds produced within the body
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Bronchial Sounds
- hear over trachea
- high-pitched
- expiration > inspiration
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Bronchovesicular Sounds
- heard over mainstem bronchus
- "blowing" sounds
- inspiration = expiration
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Bruits
- abnormal "swoosh" sounds similar to murmur
- made over major blood vessels
- partially blocked artery
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Comprehensive Assessment
- when patient first enters setting
- history and physical
- provides a baseline
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Crackles
- fine to coarse crackling noise
- made as air moves through wet secretions
- on inspiration
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Cyanosis
bluish/grayish color in response to inadequate oxygenation
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Arcus Senilis
white ring around cornea
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Diaphoresis
excessive perspiration
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Eccymosis
- Bruise
- collection of blood in subQ
- purpleish-bluish color
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Ectropion
outward turn of lower eyelid
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Entropion
inward turn of lower eyelid
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Edema
excess fluid in tissues
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Emergency Assessment
- rapid focused assessment to determine potentially fatal situations
- (ABCs of CPR)
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Erosion
- loss of superficial epidermis
- moist, nonbleeding
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Erythema
redness of skin (face, neck)
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Excoriation
scratch of the epidermis
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Fissure
- deep linear crack
- extends into dermis
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Focused Assessment
- assess a specific problem
- question related factors
- physically assess vitals and specific area
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Friction Rub
- grating sound
- inflamed pleura against chest wall
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Gynecomastia
enlargement of one or both breasts in pubescent boys
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Glasgow Coma Scale
- assess level of consciousness
- eye opening, motor response, verbal response
- 7 or less: defines coma
- 15: maximum score
- Get a ballpark, then find deficit
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Inspection
process of performing deliberate, purposeful observation in a systematic manner
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Hirsuitism
excessive hair on face/body
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Jaundice
- yellow skin r/t liver/gallbladder disease
- some anemia or hemolysis
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Oncholysis
separation of nail from nailbed
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Ongoing Partial Assessment
- conducted at regular intervals during care
- concentrates on indentified problems
- monitors positive/negative changes
- evaluate effectiveness of interventions
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Pallor
paleness: inadequate circulation, inadequate oxygenation of tissues
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Ptosis
drooped upper eyelids
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Pseudostrabismus
pupils at inner folds
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Palpation
use sense of touch to assess temp, turgor, texture, moisture, vibrations, shape
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Percussion
striking one object against another to produce sound
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Petechiae
- small hemorrhagic spots cause by capillary bleeding
- assess color, size, location
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Precordium
- APETMA
- Aortic
- Pulmonic
- Erb's Point
- Tricuspid
- Mitral/Apical
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Stertorous
noisy, strenuous respirations
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Turgor
- skin fullness/elasticity
- usually assessed on sternum or over clavicle
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Vesicular Breath Sounds
- soft-low pitched
- over base of lungs on inspiration
- expiration < inspiration
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Wheeze
- continuous sounds originate in small air passages narrowed by secretion, swelling, tumor
- Sibilant: musical
- Sonorous: course
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Equipment
- Stethoscope
- Opthalmoscope
- Otoscope
- Snellen Chart: vision screen test
- Nasal Speculum
- Tuning Fork
- Percussion Hammer
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