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nrs assessment

test 1

QuestionAnswer
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