Overview
Assessment
Assessment of Systems
Case study Q&A
100
What are the basic goals of assessment?
Identify your patients needs
Ensure patient safety
Establish a baseline
Collect objective and subjective data
Plan interventions
Identify signs and symptoms
100
How often should you complete an assessment on your patient?
At least once per shift
Any time there is a change in status
When the patient leaves and returns from the unit (ex: patient went to surgery)
100
Respiratory assessment
RR, depth, and effort
Lung sounds
Chest expansion and symmetry
Resp sx? cough, SOB, dyspnea, orthopnea, cyanosis
100
Lilly Brown is an 88 y.o. female with a UTI. What should we assess?
Neuro status: orientation, demeanor, speech, confusion
COCA: urine color, odor, clarity, amount
Urinary sx: incontinence, frequency, urgency, pain or burning with urination, hematuria
Systemic sx: fever, chills, fatigue, nausea, vomiting, confusion, headache
VS & Labs: Temp, BP, BUN, Cr, Na, K+
200
You're going to your patients room to do their assessment. What are the first things you do when you walk into the room?
Hand hygiene
AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you)
Confirm patient ID
200
What is objective assessment data?
Data that is measurable, factual information collected through observation, physical assessment and diagnostic testing.
Ex: Vital signs, lung sounds, labs, etc.
So if the patient is feeling SOB (subjective), check RR, O2 sats, lung sounds (objectivr data)
200
IV assessment
Is it clean, dry, intact?
Patency, drainage, dressing status
S/sx of complications: redness, swelling, heat, cool, pain, no blood return
phlebitis (inflammation of the vein), infiltration (fluid leaking into the surrounding tissue), extravasation (infiltration involving a vesicant)
200
Yvonne Masters is a 56 y.o. female with a hx of type 2 DM, and has been non-compliant with treatment. She came in due to DKA (Diabetic Ketoacidosis). What should we assess?
Psychosocial -- mental health, social support/family
Finances -- can patient afford medicine and treatment of her condition? are they struggling in other areas?
Lifestyle: diet, exercise, medication adherence, health literacy, self care (feet)
SX and management:
a. hypoglycemia (shaking, confused, LOC) --
b. hyperglycemia -- polydipsia (excessive thirst), polyuria (frequent urination), Kussmauls breathing (deep and rapid RR), fruity breath odor (ketones, lack on insulin to break it down)
Labs: BS, Ketones (UA), BMP, CBC, ABGs
300
You walk into your patients room and begin to scan the environment. What are you looking for?
Safety hazards: cords, wet floors, tangled tubes/lines, poor lighting, room clutter
Patients facial expressions/demeanor
Bed positioning: low, locked, alarm on if indicated, bed rails up (3/4 max)
Call light close by to patient
Mobility aids within reach
300
What is subjective assessment data?
What the patient tells the nurse. Information based on how they feel, their perceptions, and experiences.
Ex: I feel dizzy, I'm anxious, I feel short of breath, I have a headache
300
Skin assessment
skin color: appropriate for ethnicity, pallor, cyanosis, erythema, jaundice
temp & moisture: hot, warm, cold, dry, diaphoretic (sweating)
integrity: intact, wounds, ulcers, abrasions, bruises, scars, pressure injuries, etc
turgor: pinch on hand or clavicle
edema
cap refill: nail beds & toes
300
John Sailor is a 72 y.o. male who is experiencing a COPD exacerbation. What should we assess?
Focused respiratory assessment: RR and effort, lung sounds, chest expansion, O2 sats, cough, use of accessory muscles?
What is his baseline?
Does he use O2 at home?
Does he use CPAP?
-- machine that delivers pressurized air through a mask during sleep. keeps airway open and improves gas exchange
400
What assessment information are you gathering?
Patient ID & mental status (A&Ox4)
Vitals signs + Pain level
Head to toe assessment data
Intake and output
IV site
History + Psychosocial
400
When you go into your patients room, what three things should you confirm prior to assessing, passing medications, or completing interventions?
Patient name
Patient DOB
Allergies
400
Cardiac assessment
Heart sounds
Regular vs Irregular
VS: HR, BP
JVD -- can signify HF
Hx and cardiac devices: pacemakers, murmurs, tele, orthostatic BP issues, MI, Afib, HLD, HTN, PVD
Sx present? CP, SOB, Fatigue, dizziness
400
Matt Hope is a 48 y.o. male complaining of abdominal pain. What should we assess?
Abdomen: pain + it's location, distention, tenderness, skin, bowel sounds, abdominal guarding
Systemic sx: fever, chills, nausea, vomiting, fatigue
Last BM
VS, Labs, Diagnostics: HR, BP, Temp, CMP, CBC, UA, CT of Abd/Pelvis (gallstones, kidney stones, appendicitis, diverticulitis, pancreatitis, obstruction, ulcer, etc)
--> Endoscopy, Colonoscopy, ERCP (endoscopic retrograde cholangiopancreatography)
500
You collected your assessment data and documented your findings. What should you do with this data?
Compare it to the patient's baseline
Compare this data to this previous assessment
Identify trends! Are we trending up or down?
500
How do you determine your priority patient assessment?
ABCs --> airway, breathing, circulation
Maslow's Hierarchy of Needs
500
Gastrointestinal assessment:
Last BM & Passing flatulence -- consistency of BM, color
Auscultation of bowel sounds & palpation of all 4 quadrants
Abdomen: tender, distention, shape & symmetry, skin color
Sx: nausea, vomiting, bloating, constipation, diarrhea, etc
500
Stacy Darwin is a 22 y.o. female with altered mental status, neck pain, and a headache. What should we assess?
Neuro: orientation, mental status, affect, pupils (PERRL), seizures, headache
Head and neck: skin discoloration, swelling, asymmetry, tenderness, stiffness, muscle spasms, masses, drainage (ears, eyes, nose), sensitivity to light
Systemic sx: Nausea, vomiting, fatigue, drowsy, fever
VS, Labs/Diagnostics: BP, HR, RR, BMP, CBC, UA, drug screen, Halo test , Head CT, Lumbar puncture (CSF sample)
Dx: Meningitis