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Assessment

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FIRST step in the nursing process; systematic way of collecting data Objective data verifies the info obtained on health history

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Skills Required for Assessment

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I.P.P.A Inspection Palpation Percussion Auscultation

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Preparation

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Nurse: wash hands, confident, self-assured, comfortable with skills Patient: privacy, explanation Environment: warm, private, well-lit, eliminate distracting noises

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Approaches

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~Cephalocaudal (HEAD TO TOE) ~LEAST to MOST invasive: used with pain ~Validate subjective data: episodic, c/o injury or discomfort ~Screening: hypertension, scoliosis, diabetes, hearing, vision ~Comparison: COMPARE one side of the body with the other

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Coronal (Frontal) Plane

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Divides body into front (anterior) and back (posterior) [ventral and dorsal]

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Transverse

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Divides the body into upper (superior) and lower (inferior) halves distal (away from) ->proximal (near the origin)

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Sagittal Plane

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Divides the body into right and left parts medial (middle) -> lateral (to the sides)

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Standing

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Position in which RN performs the musculoskeletal, neurological exam

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Sitting

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Position in which RN can asess HEENT (head, ears, eyes, nose, throat), lung (posterior)

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Fowler's

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Used with pt's who have cardiac and respiratory disease

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Semi Fowler's

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Used for cardiac exam, anterior lungs, thorax, breast exam

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Recumbent (Supine)

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Used for abdominal exam, arms and legs, peripheral pulses

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Sims

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Used for posterior exam and rectal exam

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Lithotomy

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Used for vaginal exam

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Knee Chest

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Used for rectal and prostate exam

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Inspection

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"Concentrated Watching" ~Inspect each body system ~Requirements: good lighting and adequate exposure

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Smells: Fruity

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Sign of metabolic disorders accompanied by diabetic acidosis

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Smells: Alcohol

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Imbibing, ingestion of drugs containing alcohol (cough syrup)

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Smells: Smoke

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...

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Smells: GI Bleeder

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Metallic smell

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Smells: Pseudomonas

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Fruity smell

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Smells: Offensive breath

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Poor oral hygiene, dental caries, bronchitis

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Palpation

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Follows and confirms findings on inspection Factors to assess: Texture: smooth or rough Temperature: hot or cold Moisture: dry or mosit Organ location, size Vibrations, Pulsations Lumps, Masses: size, consistency Tenderness, pain: exact location

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Percussion

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Gives palpable vibrations and characteristic sounds which depicts location, size and density of an organ (assess underlying structures) as air increases in organ, sound becomes LOUDER

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Percussion

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~Size and location of organ: percussion note changes at borders ~Density of structure: air, fluid, solid organ produces a characteristic note ~Detects masses: superficial mass, palpation penetrates 5 cm ~Elicits pain: inflamed structures ~Deep tendon reflexes: intact neuromuscular system

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Two Methods of Percussion

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Direct vs Indirect

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Direct Percussion

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Immediate or Blunt Percussion; Percussing hand directly strikes the body wall (done w/ sinuses)

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Indirect Percussion

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Mediate Percussion; Involves 2 hands

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Stationary hand

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The Pleximeter How to Percuss

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Striking hand

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The Plexor (middle finger of dominant hand) How to Percuss

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How to Percuss

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Percuss in 2's (short gentle taps and enough force to get a good clear note)

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Basic Principle of Percussion

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A structure with more air produces a longer, deeper sound because it vibrates freely

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Resonant

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Medium loud, clear, hollow, heard over the LUNGS

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Hyperresonant

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Louder, booming quality, heard over a CHILD's lung

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Tympany

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Musical, drum-like, occurs over air-filled organs like the stomach, intestines

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Dull

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Muffled thud, dense organs like the LIVER and SPLEEN

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Flat

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Dead stop of the sound, over MUSCLE or BONE

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Auscultation

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Listening to sounds through the use of stethoscope; Stethoscope blocks out environmental noise

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Auscultation: Heart and blood vessels

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Listen for normal heart sounds (S1,S2), abnormal heart sounds, bruits (turbulent blood flow)

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Auscultation: Lungs

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Listen for breath sounds, adventitious sounds (abnormal breath sounds)

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Auscultation: Abdomen

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Listen for bowel sounds, bruits

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Auscultation: Thyroid

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Listen for bruits

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Stethoscope

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Ear pieces: point towards your nose Binaurals: should keep earpieces snugly in ears Tubing: 1/2 in diameter 12-14 in long Diaphragm- used to pick up HIGH pitched sounds, hold firmly against the skin Bell- used to pick up LOW pitched sounds, hold softly

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Infant

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6 months are better on mom's lap take advantage of quiet baby-> auscultate heart, lungs, abdomen Developmental Considerations

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Toddler

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Perform exam on parent's lap, allow choices Developmental Considerations

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Preschooler

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Autonomy, cooperative, like to be involved, like to see how things work Let them listen to mom's heart Developmental Considerations

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School-age child

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Modesty develops, they can decide if mom or dad can stay Developmental Considerations

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Adolescent

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In tune to their body-> best time to do health teaching, use head to toe approach Developmental Considerations

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Aging adult

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Allow for as few position changes as possible Developmental Considerations

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Ophthalmoscope

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Apatures to examine different structures in the eyes

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Otoscope

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Illuminates external canal and tympanic membrane, nasal canal

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Tuning fork

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500 - 1000 Hz auditory fork; 100 - 400 Hz sensation fork

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Percussion Hammer

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Deep tendon reflexes

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Neurologic Hammer

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Has soft brush and sharp needle for detecting sensory perception

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Tape Measure

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Circumference, length (liver span, diaphragm)

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Penlight

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View lesions with tangenital lighting (lighting from the side), pulsations

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Calipers for skinfold thickness

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Measures thickness of subcutaneous tissue

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Complete Blood Count (CBC)

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Basic screening test Hemoglobin and Hematocrit Red Blood cell count (RBC) White Blood cell count (WBC)

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Hemoglobin

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~Main intracellular proteins ~Carries O₂and removes CO₂ ~Measures total_________ in the blood ~Increases with polycythemia (increased in RBC) ~Decreases with blood loss, anemia or bone marrow supression

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Hematocrit

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~Measures PERCENT of red blood cells in the total blood volume ~Increases with polycythemia, dehydration, burns ~Decreases with blood loss, overhydration, dietary deficiency, anemia

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H and H (Hemoglobin and Hematocrit)

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Will INCREASE in dehydration WIll DECREASE in hyperbalemia

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Red Blood Cell Count (RBC)

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Number of RBCs per cubi millimeter of whole blood Low RBCs -> anemia High RBCs -> polycythemia, may develop secondary to chronic hypoxia

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White Blood Cell Count (WBC)

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Determines the number of circulating WBCs per cubic millimeter of whole blood High WBCs -> bacterial infection Low WBCs -> viral infections

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Serum Electrolytes

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Used for electrolyte and acid-base imbalances; Check for sodium, potassium, chloride, and bicarbonate ions; glucose (Ordered as Chem 7 or BMP or basal metabolic panel) Urea Creatinine

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Urea

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End product of protein metabolism, measured as (BUN)

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Creatinine

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Produced by muscles and excreted by kidneys

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Visualization Procedures: GI Tract

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Direct visualization of the GI tract (looking right at the tissue)

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Anoscopy

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Display anal canal Direct Visualization of GI Tract

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Proctoscopy

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Display of the rectum Direct Visualization of GI Tract

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Proctosigmoidoscopy

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Display of the rectum, sigmoid colon Direct Visualization of GI Tract

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Colonoscopy

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Display of the large intestine Direct Visualization of GI Tract

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Indirect Visualization

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Done with x-rays; Enhanced by radiopaque substances such as barium

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Nursing Considerations: Direct Visualizations of the GI Tract

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~pt needs to be cleaned out; Strong cathartic (GoLytely) and Dulcolax given 24 hours before test ~signed informed consent ~monitor VS and for bowel perforation ~inform pt that air is introduced during test (flatulence) ~if tissue samples were removed -> pt may experience bleeding in their stool

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Visualization Procedures: Urinary

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KUB IVP Renal Ultrasonography Cytoscopy

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KUB

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X-ray of the kidneys/ureters/bladder

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Intravenous Pyelography (IVP)

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Radiographic study to evaluate the urinary tract

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Nursing Considerations: IVP

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~Contraindicated for those who are allergic to shellfish or IDODINATED dye, dehydrated, renal failure ~Signed consent ~Metformin (medication for diabetes) is held for 24 hours ~Laxative or enema is given before test Post-op ~Maintain hydration ~Monitor I & O

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Renal Ultrasonography

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Non-invasive procedure that uses sound waves to visualize kidneys

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Cystoscopy

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BLADDER and URETHRAL orifices are visualized with a cytoscope

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Nursing Considerations: Cystoscopy

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~signed consent ~light sedation ~restrict fluid/food for 8 hours ~monitor I & O, character of urine, hydration ~check for signs and symptoms of flank pain, chills, difficulty urination

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Visualization Procedures: Cardiopulmonary

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Electrocardiography Angiography Echocardiogram Lung Scan (V/Q ventilation/perfusion scan) Laryngoscopy Bronchoscopy

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Electrocardiography

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Provides graphic recording of the heart's electrical activity; ECG can be examined to determine dysrythmias, myocardial damage, enlargement of the heart, drug effects

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Stress Electrocardiography

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Assess pt's response to increased cardiac workload

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Nursing Considerations: Stress Electrocardiography

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~Review test ~Comfortable clothes and shoes ~Review history and meds ~Check for chest pain within past 48 hours ~baseline ECG ~Monitor VS post test

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Angiography

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Radiopaque dye is injected into a vessel, flow thru vessel is assessed Coronary angiography Pulmonary angiography

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Coronary Angiography

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Used to evaluate extent of CORONARY ARTERY disease

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Pulmonary Angiography

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Used to assess pulmonary vascular system

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Nursing Considerations: Cardiopulmonary

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~Use of iodine dye ~Informed consent ~Test takes 1-2 hours ~When dye is injected, there is burning, flushing feeling ~Must lie motionless ~NPO for 8 hours ~Post-op: check VS, insertion site, pulses in extremity ~hydration

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Echocardiogram

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Uses ultrasound to visualize structures of the heart and evaluate left ventricular functioning

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Lung Scan: V/Q (ventilation/perfusion)

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Scan used to how well GAS and BLOOD travel thru the LUNGS, radioisotope is injected intravenously

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Fingertips

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Used for texture, swelling, pulsations, presence of lumps Part of the Hand Used in Palpation

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Fingers and Thumb

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Used to detect position, shape, consistency of an organ or mass Part of the Hand Used in Palpation

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Dorsa of the Hand

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Used to assess temperature Part of the Hand Used in Palpation

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Base of the Fingers (Ulnar Surface)

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Used to feel vibrations Part of the Hand Used in Palpation

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Light Palpation

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~surface characteristics, lesions, superficial masses ~press 1/2-3/4 inch ~check muscle tone, tenderness

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Deep Palpation

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~encourage pt to used imagery, slow deep breaths to relax muscles ~intermittent palpation is best ~press 2 inches to identify organs ~hold hand <60 degrees, use pads of fingers ~identify abdominal organs or masses

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Bimanual Palpation

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~Requires TWO hands ~Used to capture a body organ (kidneys, uterus, adnexa)

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Laryngoscopy and Bronchoscopy

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Test used to look at the larynx and bronchi of the lungs; local anesthetic is given to prevent the gag

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Nursing Considerations: Laryngoscopy or Bronchoscopy

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~NPO for 6-8 hours ~informed consent ~remove dentures ~provide mouthcare ~may be given general anesthesia Post-op -> semifowler's ~frequent VS ~expectorate (spit their secretions) until gag returns

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Computerized Tomography or Computerized Axial tomography (CAT) Scan

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~Distinguished minor difference in the denisty of the tissue ~Produces a 3 dimensional image ~More sensitive than X-ray

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Magnetic Resonance Imaging (MRI)

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Non-invasive (pt is placed in a magnetic field) Pts cannot have implanted metal device: ~pacemakers ~artificial joint ~body art (may contain metal pigments) ~metal body piercing jewlery ~transdermal patches Pt cannot be pregnant or clostrophobic

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Position Emission Tomography (PET) Scan

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Involves inhalation or injection of a radioisotope; Images are created as the isotope is distributed in the body Allows for the study of organ function, blood flow and tumor growth

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Nursing Considerations: PET Scan

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~Restrict alcohol, tobacco, caffein for 24 hours ~informed consent ~no metal objects Post-Op ~hydration ~radioisotope is eliminated in 6-24 hours ~flush toilet immediately, wash hands

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Aspirations

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Lumbar punctures Abdominal paracentesis Thoracentesis

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Lumbar Punctures

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Cerebrospinal fluid is drawn thru a needle inserted into the subarachnoid space between the 3rd and 4th lumbar vertebrae; Pt is positioned on side with back arched

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Nursing Considerations: Lumbar Puncture

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~baseline VS ~knee chest position Post-Op ~hydration ~pt flat -> 30 degrees for 8 hours ~check puncture site for leakage ~check for neurological changes

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Abdominal Paracentesis

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Used with patients with ascites; strict sterile technique is used ~Cannula is inserted into abdominal cavity to withdraw fluid ~Normally no more than 1500 is drained out at once to prevent hypovolemic shock ~Nursing: observe site for hematoma, pressure bandage

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Thoracentesis

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Remove excess fluid or air in the pleural space to ease breathing; Can also be used to insert chemotherapeutic drugs Strict sterile technique is used Nursing: pressure bandage on puncture site; assess for bleeding, hematoma

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Biopsies

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Removal and examination of tissue Bone marrow Liver biopsy

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Bone Marrow Biopsy

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Used to detect specific diseases of the BLOOD; Sternum, anterior or posterior iliac crest of the hip

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Liver Biopsy

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Pt will have a pressure dressing over site, lie on right side after procedure, frequent vital signs

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