Assessment/Documentation LPN – Flashcards

Introduce self- name, position, purpose, ask permission, allow ?s before beginning, give time. Communicate trust- confidentially, understanding. Professional Manner- non-judgmental, call by Mr. or Ms. Interview should be relaxed, unhurried. Convey concern. May be a patient first assessment & object is establishing a affective Nurse/patient relationship.

introduce self, develop rapport, nursing history, physical assessment, and etc... health HX per client/family, why seeking care now and psychosocial.

Medical assessment/physical exam by physician- detailed medical exam w/ lab valve and tests results. LPN does assistive functions. detailed medical exam w/ lab valve and tests results. initial assessment = Initial assessment-(on-going) beginning of each shift-general assessment-w/attention to admission medical diagnosis admission assessment = Initial comprehensive admission assessment- comprehensive assessment performed on pt admission usually by RN focus assessment = Focused assessment -concentrates on particular part of the body by LPN. involves specific set of observations r/t condition or disorder (neurological-head trauma, post-op surgery-hemorrhage, neurovascular -ck cir., Finger stick blood sugar(FSBS)

a focused assessment. neurological-head trauma, post-op surgery-hemorrhage,. neurovascular -ck cir., Finger stick blood sugar(FSBS). Neurological asses: includes LOC, verbal clues (can they comply correctly), Motor function (move extremities, smile, lift brows), pupillary response (pen light), proprioception (sensation of body movements & posture awareness), deep tendon reflexes, cranial nerve assessment (done by RN)

Bruits: Auscultation of the carotid artery can be per- formed by listening with the bell of the stethoscope. Normally, no bruits are audible. Bruits are abnormal "swishing" sounds heard over organs, glands, and arteries. A + bruit may indicate vessel blockage. Homan's sign: + Homas's or no palpable pulse may indicate-thrombosis-blood clot. Examine the patient's legs by stretching and straight- ening each leg, then using dorsiflexion on the foot. Pain in the calf is a positive Homans' sign, possible thrombophlebitis. Notify the physician promptly. neurovascular: circulation check: circulation, motion, sensation. Paresthesia, pallor, pain

the nurse determines the patient's level of consciousness (LOC) and level of orientation. Is the patient oriented to person, place, time, and situation/purpose?

Objective data- observable, felt, measurable signs. Eg: Erythema area, edema. Abdomen- distended w/active bowel sounds in 4 quadrants. Infiltration of IV. Rash of skin. Edema goes to gravity-see rating sheet. Wound drainage- color ; amt. Exudate-slow drainage. Foley catheter patent w/ clear straw urine Subjective data-Symptoms as perceived by client. Pain, anxiety, nausea, aching, no BM X 3 days. Fatigue ; tiredness. Dizzy, Burning, tingling. Nurse needs to inquire onset, course, duration ; character

Interviews-health Hx per client/family, why seeking care now and psychosocial Hx Inspection = Purposeful observation of physical ; behaviors Auscultation = Listening w/ steth to body sounds (CV, Lungs, GI) Palpation = Feeling w/ fingertips density and placement of organs Percussion = Finger tips to tap over organs (vibrations) low pitch ; high pitch over gas

Assessment is easier in areas where the epidermis is thin, such as the lips and mucous membranes. The darker a person's skin, the more difficult it is to assess for changes in color, Color cannot be used as an indicator of systemic conditions in darker skinned individuals (e.g., flushed skin with fever). Establish a baseline in natural lighting if possible or with (at least) a 60-watt light bulb. Assess baseline skin color in areas with the least pigmentation, such as palms of the hands, soles of the feet, underside of forearms, abdomen, and buttocks. All skin colors have an underlying red tone. Pallor in black-skinned individuals is seen as ashen or gray. Pallor in brown-skinned individuals appears as yellowish. Assess pallor in mucous membranes, lips, nailbeds, and conjunctivae (i.e., the inner surface) of the lower eyelids. To assess rashes and skin inflammation in dark-skinned individuals, rely on palpation for warmth and induration (i.e., an abnormally hard spot) rather than observation.

dehydration =decreased skin turgor and is manifested by lax skin that, when grasped and raised between two fingers, slowly returns to its previous position (skin "tenting"). MM look dry. (skin = warm,dry,pale, decreased skin turgor) carotid bruit = Palpate the carotid arteries gently and one at a time. The normal carotid pulse is regular and palpable without a thrill (a vibrating sensation the nurse perceives during palpation along the artery). Auscultation of the carotid artery can be per-formed by listening with the bell of the stethoscope. Normally, no bruits are audible. Bruits are abnormal "swishing" sounds heard over organs, glands, and arteries. A bruit results from an abnormality in an artery that results from a narrow or partially occluded artery, such as occurs in atherosclerosis JVD = Inspect for jugular venous distention. The jugular veins give information about activity on the right side of the heart. Specifically, they reflect filling pressure and volume changes. Distention results when ineffec-tive pumping action of the right ventricle causes increased volume and pressure within the veins. Normally the veins are not observable with the patient in a sitting position. Jugular venous distention is seen in venous hypertension or right-sided heart failure. PERRLA =Pupils Equal, Round, Reactive to Light & Accommodation (PERRLA). Use pen light & watch pupils dilate. abnormal mucous membranes = Inspect the lips and the mucous membranes of the mouth with a tongue blade and penlight, assessing all surfaces of the oral cavity. Normal mucous membranes are moist, pink, and free of lesions. Breath odors often indicate disease; foul, fruity, or musty breath is not normal.

assess heart, chest, lungs w/ patient sitting w/ arms across in lap. Lungs: auscultation to breathing. listen for one full inspiratory-expiratory cycle. listen under clothing, use zigzag approach, compare sides. Adventitious breath sounds are:Crackles/Rales or Wheezes. Listen 4 on front& 6 on back.

note any drainage, Bladder distention-firm mound over supra-pubic area, if continent, Foley catheter/specimen collection in progress Urinate -color, difficulty, frequency- 24hr urine collection?

Edema = check for pitting = press against a bony prominence 5 sec, watch skin for rebounding ; feel area for a indentation. if skin rebounds immediately theres no pitting edema. an indention indicates pitting edema. (trace, mild, moderate, severe). no pitting isn't graded. edema w/out pitting & unilateral edema maybe due to a occlusion of a major vein.

is to establish appropriate nursing diagnosis and interventions for the client

to develop a database for basing an individualized plan of care-(is True statement)

small amount is normal & large amount = vaginal infection.

inflammation = protective response of the body tissues to irritation, injury, or invasion by disease-producing organisms. infection =caused by invasion of microorganisms: virus, bacteria, fungi, etc. that produce tissue damage.

acute = begins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment. chronic = disease develops slowly and persists over a long, often for a person's lifetime. remission of disease = a partial or complete disappearance of clinical and subjective characteristics of the disease has occurred. signs = objective data as perceived by the examiner. what the nurse sees, hears, measures, and feels. symptoms = subjective indications of illness the patient perceives. risk factors = a risk factor is any situation, habit, environmental condition, genetic predisposition, physiologic condition, or other variable that increases the vulnerability of an individual or group to illness or accident. nursing diagnosis = a type of health problem that can be identified disease of the body = a pathologic condition of body is any disturbance of a structure or function of the body. **Etiology = cause Hereditary = transmitted genetically from parents to children Inflammatory = the body reacts with an inflammatory response to some causative agent. Degenerative = disease implies degeneration, often progressive of some par to the body. erythema = superficial reddening of skin purulent = discharging pus edema = swelling

obj = what i feel/see. Subj = what pt says.

traditional block, and POMR (problem oriented medical record)

2 common types of medical records or charts: 1) Block or traditional charting = Divided into specific sections or blocks, Emphasis is placed on specific sheets of info, Flow sheets, graphics, and narrative charting 2) POMR = Problem Oriented Medical Record. Based on problem-solving method. Principle sections are data base, problem list, initial plan and progress notes. i.e.: SOAPIER, SOAPE. POMR uses master patient problem list as an index to the chart. These listed problems are usually medical diagnoses. 2a) SOAPIER = 1 way of charting in POMR. S subjective info is what the patient states or feels . O objective info that the nurse can measure or factually describe. Aassessment refers to analysis or potential diagnosis of the cause. P plan is the general statement of the plan of care to be given. Implementation is the care given or action taken. Evaluation is the effectiveness of the plan Revision includes changes that may be made to original plan. 2B) • SOAPE = Stands for the same as SOAPIER. Implementation is included in the plan notes.Revisions are noted in the evaluation sections, after the response has been evaluated. 2 common formats for charing nurses notes: 1) Narrative Charting: Writing out in abbreviated story. Includes the patient's problems, care and treatment, communications with other health team members and response to care. 2) Focus charting = Can be used with both block(traditional) and POMR charting.Uses a modified list of nursing diagnoses. Serves as an index for nursing documentation. Uses the Nursing Process, Uses DAR format - D=data, A=action, R=response or evaluation, E=education or patient teaching. -- • Charting by exception, CBE = Based on assumption that all standards of practice are carried out & met with a normal or expected response unless otherwise documented. Beginning each shift a complete assessment is done and documented. Only additional treatments done or withheld, new patient concerns, or change in condition are charted. More detailed flow sheets are used to ? time. • APIE = A= assessmentt, P= plan, I= intervention, E= evaluation, Example of charting by exception.

note it as late entry & proceed w/ your notation. i.e.: late entry_____. or as dictated by facility policy.

pT may not have immediate access to their full record, depending on agency policy (p54)

identify error according to facility police and make the correct entry. (P 42,55) then add correct info & date & initial entry.

A tool rather than part of the record Quick reference, Updated daily and with physician's orders, Usually written in pencil so easy to change daily. Contains: Room number, pt name, age, sex and admitting diagnosis, and physician's name. Date of surgery. Type of diet. Scheduled tests or procedures. Level of activity permitted. Nsg orders for assistive or comfort measure. IV fluids ordered.

time & method of transportation on departure & return

if you question a order record that clarification was sought. i.e.: "dr. badly was called to clarify order for_____."

divided into sections or blocks. emphasis is placed on spacific sections of info, i.e.: progress notes, graphics, nursing notes. Narrative charting is used: nurse documents in story form all pertinent pt observations, care, and responses in nurse's notes section of the patient's records. narrative charting includes: data (Subject & object) about the basic pt need or problem, if someone was consulted, care & treatments provided and the patient's response to treatment (implementation, evaluation). this is a abbreviated story form.