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nrs assessment
test 1
| Question | Answer |
|---|---|
| Assessment | a systematic approach to gather information about the patient and their needs. |
| Subjective Data | symptoms only felt and described by the patient. |
| Objective Data | signs that can be detected by the nurse, which are observable and measurable; factual data. |
| primary source | source of data= the patient; most reliable and most valuable |
| secondary source | source of data= friends, family, other healthcare team members and the chart. |
| Two main types of assessment | Complete and Focused |
| complete assessment | head-to toe data based assessment |
| Focused Assessment | more detailed about a specific problem; may be repeated at designated times with a combination of structured and unstructured questions. |
| Methods of data collection | observation, interview and examination |
| Four techniques involved in examination | inspection, auscultation(listening to sounds), palpation(feeling and touching), percussion(tapping) |
| neurological status includes | level of consciousness and orientation status(person, place and time), speech and hand grips(= pressure in both hands) |
| Skin and hair assessment | color(pink, blue or purple), temperature(warm or cold), moisture(dry or moist), turgor(tenting), lesions and abnormal findings with hair and nails. |
| head and neck assessment | typically only document abnormalities |
| Mouth/throat assessment | emphasis on mucous membranes being pink, moist and intact (make sure to specify in notes whether mouth, nose or eye) |
| Eyes assessment | usually done as part of neuro.; check pupils; PERRLA=pupils are equal, round, reactive to light, accommodation(near to far pupil change) |
| Chest/lings/heart assessment | chest expands evenly with unlabored resp. about 18/min, breath sounds clear(anterior, posterior and bi-laterally), listen for apical pulse(listen for 1 full minute noting regularity), capillary refill(press nail, should refill in 3 sec.) |
| Pulses to document usually include | radial, apical and pedal |
| Abdomen assessment | listen with stethescope prior to palpating, noting bowel sounds; check each quad. for 1 min. (4-32 per minute is normal) and note shape of abdomen |
| If you hear no bowel sounds in any one quad. | you should listen for 5 minutes to double check before recording |
| genitourinary assessment | urine color, clarity, and smell |
| feet/ legs assessment | check for edema |
| musculoskeletal assessment | check for range of motion and note ambulation assistance |
Created by:
laceynickie
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