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Assessment
Final
| Question | Answer |
|---|---|
| COLDSPA | C- Character O- Onset L- Location D- Duration S- Severity P- Pattern A- Associated Factors |
| Nonverbals | -Appearance -Demeanor -Attitude -Facial Expression -Silence -Listening |
| Nonverbal Communication to Avoid | -Excessive or insufficient eye contact -Distraction and distance -Standing if possible (never sit on a client's bed) |
| Palpation | -Light- < 1cm pulse, temp, moisture, texture, tenderness, circular motions -Moderate - 1-2cm organs and masses; size, consistency, and mobility -Deep- 2.5-5cm, push down deep to feel organs covered by muscle -Bimanual- 2 hands, uterus, breasts, splee |
| Percussion: Purpose | -Elicit pain and reflex -Determine location,size,shape, and density -Detecting abnormal mass |
| Percussion: Types | -Direct-tap body part w/ fingertips to elicit tenderness(sinuses) -Blunt-1 hand on body,the other strike hand;detect tenderness of organ -Indirect/Mediate-Most common,tapping produces sound/tone;density I&tone D;tissue=soft, fluid=loud,air=louder |
| Patient Positions | Dorsal Recumben is where the nurse can feel the peripheral pulses -On Back, Knees up, Hands over head |
| Subjective Data | -Can be verified by patient -What patient tells you -Provides nurse with clues -Includes: symptoms, feelings, desires, preferences,beliefs, values,ideas,life and health history |
| Objective Data | -What you observe |
| Vital Signs | Temperature - 96.0 - 99.9 Pulse - 60 - 100 Respiration - 12 - 20 bpm BP - 120/80 Optional 5th sign,pain |
| Temperature | -Oral:3 mins w/ a glass thermometer -Rectal:.5-1 higher than oral -Axillary:.5-1 lower than oral -Tympanic:.5-1 higher than oral -High temp=high pulse -Earlier in day=low temp -Highest temp later @ night -Exercise= > temp -Older adult=lower |
| Blood Pressure | -Measures pressure on the walls of the arteries -Systolic: ventricles contract -Diastolic: ventricles at rest -Avoid nicotine and caffeine before taking bp |
| Pulse | -Tachycardia: > 100 -Bradycardia: < 60 -+1 thready, +2 normal, +3 bounding |
| Developmental Level | -Young Adult: Intimacy vs. Isolation -Middlescent: Generativity vs. stagnation -Older Adult: Ego integrity vs. Despair |
| Recent Memory | -Ask the client what did you have to eat today or what is the weather like today |
| Remote Memory | -Ask the client when did you get your first job, when is your birthday; Info on past health history also gives clues as to the client's ability to recall remote events -Inability=cerebral cortex disorders |
| Quoting Clients' Responses | - Rephrasing lets the client know that you're paying attention/understand |
| Good Communication | -Open-ended questions -Close-ended questions (facts) -Laundry list -Rephrasing |
| Permission of client | -Client always has the right to refuse |
| Abnormal Nails | -Pale or cyanotic=hypoxia or anemia -Splinter hemorrhages=trauma -Beau's lines= acute illness -Yellow discoloration=fungal infection, psoriasis -Spoon nails = iron deficiency -Thickened nail= D circ -Paronychia=infection -Onycholysis=inf, traum |
| Cancer (ABCDE) | A - Asymmetrical B - Borders (irregular) C - Color Variations D - Diameter exceeding 1/8 to 1/4 of an inch E - Elevated, not flat |
| Common Skin Variations | -Freckles -Vitiligo (lighter spotting) -Striae -Seborrheic Keratosis (warty,crusty pigmented lesion) -Scar -Mole -Cutaneous tags (raised yellow papules w/ depressed center) -Cutaneous horn -Cherry Angiomas |
| Pressure Ulcer Staging | 0-Closed/Resurfaced-completely covered w/new skin 1-Epithelial-new pink or shiny tissue 2-Granulation-Pink red,shiny moist 3-Slough-yellow/white adheres to ulcer in strings or clumps, mucinous 4-Necrotic- Eschar, black brown adheres to wound or ulce |
| Cranial Nerves of the Neck | -11th Cranial nerve is responsible for muscle movement that permits shrugging of the shoulders and turning the head against resistance |
| Migraine Headache | -Location: Around eyes,temples,cheeks,forehead -Severity: Throbbing, severe, recurring |
| Cluster Headache | -Accompanies by tearing, eyelid drooping, reddened eye or runny nose -Sudden onset -Location:Eye and orbit and radiating into facial and temporal -Severity: Intense, Stabbing |
| Tension Headache | -Symptoms of anxiety, tension and depression -Location: Frontal, temporal, occipital region -Lasts days, months or years -Severity: dull, aching, tight diffuse |
| TMJ | -Temporomandibular Joint -Place index finger over front of each ear as you ask client to open mouth |
| Rinne Test | -Tuning fork to mastoid process then external ear |
| Weber Test | -Tuning fork on top of hear -Louder in one ear than the other? |
| Conductive Hearing loss | -Bone conduction hear longer or equally as long as air -Rinne - don't hear vibrations with fork in front of ear |
| Sensorineural Hearing loss | -Perceptive hearing loss -Air conduction heard longer |
| Presbycusis | -50+ years -Don't hear high pitched frequencies |
| PERRLA | Pupils are equal, round, react to light and accommodation |
| Structural problems of the nose | -Nasal Polyp -Perforated Septum |
| Breath Sounds: Posterior | -Bronchial = Can't be heard -BV = Moderate sound, between the scapula -V = Low, soft, Periphery, long inspiration and short expiration |
| Breath Sounds: Anterior | -Bronchial = High, loud, short inspiration, long expiration, Traches -BV = moderate, Sternum -V = Low, soft, long inspiration, short expiration, Periphery |
| Types of Breathing | -Tachypnea - >24/min, shallow -Bradypnea - < 10/min, regular, normal w/ athletes -Apnea - no breathing -Kussmaul's Respirations - deep,labored breathing associated w/ metabolic acidosis |
| Crackles (fine) | -High pitched, short, heard during inspiration, discontinuous |
| Crackles (coarse) | -Low pitched, bubbling, moist sounds persist from early inspiration to early expiration |
| Pleural Friction Rub | -Low pitched, dry, grating sounds, continuous sounds like crackles but occurs during inspiration and expiration, pleuritis |
| Wheeze (sibilant) | -Continuous, high pitched, musical sounds heard during expiration but also can be heard during inspiration, acute asthma or chronic emphysema |
| Wheeze (sonorous) | -Continuous, low pitched, snoring, or moaning sounds heard primarily during expiration but may be heard throughout resp. cycle, wheezes may clear with coughing |
| COPD | -Obstruct airflow from alveoli -2 most common conditions:emphysema, chronic bronchitis -Smoking greatest cause |
| Smoking Pack Year History | -Number of packs x Number of years |
| Right Upper Quadrant | -Ascending and transverse colon -Duodenum -Gallbladder -Hepatic flexure of colon -Liver -Pancreatic head -Pylorus -Right adrenal gland -Right Kidney -Right ureter |
| Right Lower Quadrant | -Appendix -Ascending colon -Cecum -Right Kidney -Right ovary and tube -Right ureter -Right spermatic cord |
| Left Upper Quadrant | -Left adrenal gland -Left kidney -Left ureter -Pancreas -Spleen -Stomach -Transverse descending colon |
| Left Lower Quadrant | -Left Kidney -Left ovary and tube -Left ureter -Left spermatic cord -Descending and sigmoid colon -Left spermatic cord |
| Order of Abdominal Assessment | -Inspect -Auscultate -Percussion -Palpate |
| Carotid Artery | -Should not be any swishing or blowing -Auscultate middle age or older -Bruit-occlusive artery disease, 2/3 closed bruit may not be heard -Thrill-abnormal tremor accompanying a murmur = narrowing of artery |
| Jugular Vein Distention | -Indicates increased central venous pressure that may be the result of right ventricular failure, pulmonary hypertension, pulmonary emboli or cardiac tamponade |
| Pulse Deficit | -Difference b/w the apical and peripheral/radial pulses -May indicate atrial fibrillation, atrial flutter, premature ventricular contractions, and varying degrees of heart block |
| Areas of Listening to the Heart | -Aortic-2nd ICS @ R Sternal border (base) -Pulmonic-2nd ICS @ L sternal border -Erb's point-3rd ICS near L midclavicular line -Tricuspid-4th/5th ICS @ L lower sternal border -Mitral-5th ICS near L midclavicular line (apex) |
| S3 | -Ventricular Gallop, can be heard early in diastole after S2 -Best heard using bell @ apical area -Rhythm=Kentucky -Extra beat@end -Normal in young children,and pregnancy -Rarely normal in ppl over 40 -Associated w/CHF,myocardial failure, volume ov |
| S4 | -Atrial gallop heard late in diastole, just b/f S1 -Best heard using bell over apical area w/patient supine or L lateral -Rhythm=Tennessee -Extra beat @beginning -Can be normal in trained athletes -usually an abnormal finding associated with CAD,HTN |
| Murmurs | -Swishing sound caused by turbulent blood flow through the heart valves/great vessels -Pan-Means all throughout |
| Physiologic Murmur | -Caused by temporary increase in blood flow. Can occur with anemia, pregnancy, fever and hyperthyroidism |
| Innocent Murmur | -Not associated w/any physiologic abnormality,they occur when the ejection of blood into the aorta is turbulent, very common in kids and young adults |
| Jugular Venous Pressure | -Asst- of venous pulse helps determine the hemodynamics of the right side of the heart -R sided HF raises pressure and volume, raises jugular venous pressure -Decreased jugular venous pressure occurs w/reduced L ventricular output or reduced blood volum |
| Capillary Refill | -If exceeds 2 seconds may indicate vasoconstriction,decreased cardiac output,shock,arterial occlusion or hypothermia |
| Homan's Sign | -Screening for thrombophebitis -Client supine -Flex knee about 5* -Place hand under calf musc, and dorsiflex of foot -Pain or tenderness? -No pain or tenderness=negative |
| Allen's Test | -Evaluates patency of radial/ulnar arteries -Begin w/ulnar patency -Client rest hand palm side up,make fist -Use thumbs to occlude arteries -Continue pressing, client release fist -Note palm remains pale -Release pressure,watch for color return |
| Assessment of Breast | -Milky discharge normal - pregnancy, lactation -Masses/Lumps: Malignant=Upper outer quad, irregular, poorly define borders,hard,nontender, fixed to underlying tissue |
| Fibroadenomas | -1-5cm round,oval,mobile,firm,solid, elastic,nontender, unilateral or bilateral |
| Fibrosystic Breast Disease | -Round, elastic, defined, tender, mobile cysts, most common 30 yo- menopause (50) |
| Function of Bones | -Provide Structure -Give Protection -Serve as levers -Store Calcium -Produce blood cells |
| Osteoporosis: Risk Factors | Uncontrollable:gender,age,body size,ethnicity,bone fractures Modifiable:lack of exercise,low calcium,low estrogen levels, smoking,caffeine,alcohol, medication intake |
| Osteoporosis: Risk Reduction | -Increase physical activity; increase calcium and vit D -Avoid excessive caffeine, alcohol, steroids, smoking -Estrogen replacement therapy, prevents falls |
| Osteoporosis: Sociocultural | -Men have denser bones than women -Blacks have denser bones than whites -Bone density of Chinese, Japanese, and Eskimo individuals below that of Caucasians |
| Abnormal Spinal Curvatures | -Flattening of lumbar curve: herniated lumbar disc or ankylosing spondylitis -Kyphosis:older adults,rounded thorax -Lumbar Lordosis:exaggerated lumbar curve,pregnancy or obesity -Scoliosis:lateral curvature |
| Foot Drop | -Client lifts foot and knee high w/ each step, then slaps the foot down hard on the ground -Client can't walk on heels -Characteristic of diseases of the lower motor neurons |
| Phalen's Test | -Ask client to place backs of both hands against each other while flexing the wrists 90* downwards -Client holds this for 60 seconds |
| Tinel's Sign | -With your finger, percuss lightly over the median nerve (located on the inner aspect of the wrist) |
| Assessing Edema | 1+ Mild, slight indentation,no perceptible swelling of the leg 2+ Moderate,indentation subsides rapidly 3+ Deep,indentation remains for a short time, leg looks swollen 4+ Very deep pitting, indentation lasts a long time, leg is very swollen |
| Grading Reflexes | -0-No response -1+ Decreased, less active than normal -2+ Normal, usually response -3+ More brisk or active than normal, but not indicative of a disorder -4+ Hyperactive, very brisk, rhythmic oscillations; abnormal and indicative of disorder |
| Decorticate | -Client with lesions of the corticospinal tract draws hands up to chest when stimulated -Abnormal Flexor posture |
| Decerebrate | -Client with lesions of the diencephalon,mibrain,or pons extends arms and legs, arches neck and rotates hands and arms internally when stimulated -Abnormal extensor posture |
| S&S of a Stroke | -Sudden numbness especially on one side -Sudden confusion,trouble speaking, understanding speech -Sudden vision problems in one or both eyes -Sudden trouble walking, dizziness, loss of balance, or coordination -Sudden severe HA with no known cause |
| CN I | -Olfactory -Close eyes, Occlude one nostril and identify scented object |
| CN II | -Optic -Snellen Chart assess vision -Opthalmascope to view retina and optic disc |
| CN III, IV, VI | -Oculomotor, Trochlear, Abducens -Indirect and Direct test -Ptosis-drooping seen w/ weak eye musc, myasthenia gravis -Dilated=oculomotor paralysis -Unilateral dilated unresponsive to light = damage oculomotor -Constricted unresponsive = lesions o |
| CN V | -Trigeminal -Motor function:Clench teeth and palpate temporal and masseter musc for contraction, should be able to contract bilaterlly -Sensory:Sharp,dull. Close eyes and have them tell you which it is |
| CN V: Corneal reflex | -Client look away and up while you lightly touch cornea with cotton -Eyes should blink bilaterally |
| CN VII | -Facial -Motor Function:Smile, frown, show teeth etc -Movements should all be symmetrical -Sensory function not normally tested; ask client to identify flavor on tongue |
| CN VIII | -Acoustic/Vestibulocochlear -Hearing -Weber and Rinne tests |
| CN IX, X | -Glossopharyngeal, Vagus -Motor: say ah, uvula and soft palate raise bilaterally and symmetrically -Gag reflex: touch post. pharynx |
| CN XI | -Spinal Accessory -Shrug shoulders against resistance of trapezius muscle -Turn head against resistance |
| CN XII | -Hypoglossal -Strength and mobility: Protrude tongue, move it to each side against resistance |
| Gait | -Ask client to walk naturally across room -Should be steady, opposite arms should swing -Gait can be affected by disorders of motor sensory, vestibular, cerebellar systems -Romberg test |
| Tandem Walking | -Walk heel to toe fashion, then on heels and then toes -Demonstrate walk first and stand close by in case client loses balance -Should maintain balance with tandem walking and walk on heels and toes with little difficulty |
| Abnormal Gait | -Cerebellar Ataxia -Parkinsonian Gait -Scissors Gait -Spastic Hemiparesis -Footdrop |
| Cerebellar Ataxia | -Wide-based, staggering, unsteady gait -Romberg test results positive -Seen with cerebellar disease or alcohol or drug intoxification |
| Parkinsonian Gait | -Shuffling gait, turns accomplished in very stiff manner -Stooped-over posture w/ flexed hips and knees -Typically seen in Parkinson's disease and drug-induced parkinsonian because of effects on basal ganglia |
| Scissors Gait | -Stiff, short gait -Thighs overlap each other with each step -Seen with partial paralysis of legs |
| Spastic Hemiparesis | -Flexed arm held close to body while client drags toe of leg or circles it stiffly outward and forward -Seen with lesions of upper motor neurons in cortical spinal tract, such as occurs in stroke |
| Reactions to Pain | -Emotional and Psychological -Increased VS -Decreased GI and urinary function -Increased release of hormones and neurotransmitters -Metabolic disturbances -Muscular dysfunction |
| Cancer Pain | -Often due to compression of peripheral nerves of meninges or from the damage to these structures following surgery, chemo, radiation or tumor growth and infiltration |
| PCA Pump | -Patient Controlled Analgesia -Let's patients control their own medication without nurse being present |
| Healing | -Pain assists with healing |
| Order of Assessment | -Temperature -Pulse -Respirations -Blood pressure -Mental health -Head -Eyes -Nose -Neck -Arms -Posterior lungs -Anterior lungs -Heart -Abodomen -Legs/feet |
| Brainstem Injuries - Breathing | -A patient will not be able to breath on their own with a brainstem injury |
| Basis of Pain | -Psychological -Emotional -Physical appearance -Increased vital signs -Decreased gastrointestinal and urinary function -Increased release of hormones and neurotransmitters -Metabolic disturbances -Muscular dysfunction- spasms |
Created by:
prettyinpink7
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