do patients require a hed-to-toe assessment during every 24 hour stay in the hospital?
no..
they require a consistent specialized examination that focuses on certain parameters at least every 8 hours
some data from assessments must be measured very…
carefully! this depends entirely on the consistency from nurse to nurse
-includes daily weights, abnormal girth, circumference of a limb
what is SOAP?
-charting to organize findings related to a clinical problem, clinical reasoning
what is SBAR?
facilitates urgent communication between health providers
assessments must be thorough and accurate but also…?
completed rapidly! you have to assess many patients so you have to find a system that works to complete fast without seeming hurried
where does your knowledge base form from?
what you read in the chart, heard in report, results of lab tests of diagnostic imaging
health history/ initial interview includes:
- refer to what youve heard from the previous shift in the process of your own questioning (so u dont repeat things that have been asked before)
- assess for pain
- determine whether further dosing is needed and u have to contact physician
- offer water if allowed (note the physical data that this offer elicits)
- verify they have the correct name band
what is general appearance?
- facial expression
- body position
- LOC
- skin colour
- nutritional status
- speech
- hearing
- personal hygiene
measurements to do with patient?
- baseline vital signs
- oxygen sat (maintain at 92 or over)
- ask patient to rate pain level on scale of 0-10, at rest and w/ activity
things to assess in neurological assessment?
- whether patients eyes open spontaneously to name
- note patients motor response (equal bilaterally)
- note patients verbal response (clear and accurate speech?)
- measure right and left pupil sizes in mm and assess rxn to light
- assess muscle strength of extremities
- evaluate sensation (if indicated)
- assess ability to swallow
things to assess in resp system?
- if patient is receiving oxygen by mask or prongs, check fitting
- note fraction of inspired oxygen (Fi02)
- assess resp effort
- SOB?
- auscultate breath sounds, compare sides
- instruct patient to cough and breathe deeply
- if use of incentive spirometer- encourage pt to use once every hour for 10 inspirations
things to assess in cardiovascular system?
- auscultate rhythm at apex (regular or irregular?)
- check apical pulse against radial pulse
- assess heart sounds in all auscultatory areas, firm with diaphragm then bell
- capillary refil
- assess for pretibial edema
- palpate posterior tibial pulse and dorsalis pedis pulse in both feet
- verify correct IV solution is flowing at right rate
things to assess in integumentary system?
- colour, consistency
- palpate temp, should be warm and dry
- pinch up a fold of skin under clavicle or on forearm to note mobility and turgor
- note skin integrity, lesions, condition of any dressings
- note date on IV site and surrounding skin condition
- complete any standardized scales used to quantify the risk of skin breakdown
things to assess on abdomen?
- assess contour: flat, rounded, protuberant?
- listen to bowel sounds in 4 quad
- light palpation in 4 quad
- nausea, vomiting?
- passing stool, constipation, diarrhea?
- date of LBM?
- check drainage tube placement for colour, consistency, odour, amount, evaluate integrity of insertion site
- check any stoma for colour, moisture, excoriation, bleeding
- determine whether pt is tolerating ice chips, liquids, or solids
things to assess in GU system?
-voiding regularly? assess catheter if indicated
-check urine for color and clarity
if catheter is in place: check colour, quantity, clarity
if urine output is less than expected, bladder scale
things to assess for activity?
- if pt is on bed rest, HOB should be angled at 15 degrees or higher
- note if at risk for skin breakdown
- if pt is ambulatory, assist to sitting position and move them to chair
- note any assistance needed (how pt tolerates movement, ability to turn, distance walked)
- complete any standardized scales used to quantify the patients risk of falling
- if antiembolism compression stockings- pt needs to use them 22-24 hours, make sure they are on
what are critical findings that you would report if seen in assessment?
- variations from regular vitals
- urine output less than 30ml per hour for 2 hours
- dark amber urine or bloody urine
- post op nausea or vomiting not relieved with meds
- surgical pain not controlled with meds
- bleeding
- altered LOC
- sudden restlessness or anxiety
