Transcript 5 MINUTE ASSESSMENT - American Dream Review

5 MINUTE
ASSESSMENT
Arthur Cantos RN, MAN
American Dream Review
Institute Inc.
WHY DO YOU NEED
TO PERFORM
ASSESSMENT
American Dream Review
Institute Inc.
THE 5 STEP
NURSING PROCESS
Step 1: Assessment
Complete data? Lab & x-ray?
Multidisciplinary? What is going on?
What are my patient’s Learning needs?
Step 2: Diagnosis
Step 5: Evaluation
Make a Difference?
Modify Plan?
Accomplish Outcomes?
Potential Problems?
Top 2 Priorities?
Two Measurable Outcomes?
Step 3: Planning
Step 4: Implementation
Am I Being Effective? Efficient?
Have I Delegated Properly?
What Shall I do?
Interdisciplinary?
Resources and Timeline?
Not Just Technical Care
Involve Patient and Family?
Your Patients for the day
1. Mr. Puso, 52 y/o male patient of Dr. Nerva, Left
sided CHF with pulm edema, CAD and angina
2. Mrs. Asukar, 65 y/o female patient of Dr.
Tormes, long-term Type I diabetic, admitted for
episode of hypoglycemia yesterday
3. Mr. Baga, 70 y/o chronic COPD of Dr. Dy,
admitted for dyspnea episode 2 days ago
4. Mrs. Tiyan, 45 y/o s/p exploratory laparotomy of
Dr. Espiritu, yesterday afternoon
5. Waiting for new admission from PACU – Mr.
Bahag-Hari, s/p suprapubic prostatectomy of
Dr. Sy.
4
LIGHTS
CAMERA
ACTION
It’s Showtime !!!
American Dream Review
Institute Inc.
5
INTRODUCTION
1. Knock
2. Greetings
3. Introduction
– Introduce self and
members of the team
– Identification and role /
function
– Purpose of assessment
– Provide privacy
4. Plan of Care
American Dream Review
Institute Inc.
6
Perform
5. Wash hands
6. Vital Signs
Pulse Rate, Strength, Regularity
Temperature________ Oral, Rectal, Tympanic
Respiration_______________
B / P_________
Pain Assessment _________________
Oxygen saturation ________________
9
Head to Toe - Neuro
7. Orientation – time, person, place,
reason
What year is this ?
________________________
Tell me your name ?
_______________________
Tell me where you are ?
____________________
Tell me why you are
here?__________________
8. Pupil Check
( PERRLA ) Pupils, Equal, Round, React to
light, Accommodate
Sluggish ( ) No Change ( ) Brisk ( ) Normal ( )
Accommodation Yes ( ) No ( )
7/16/2015
Free Template from www.brainybetty.com
10
Mr. Puso
Mr. Puso, 52 y/o male
patient of Dr. Nerva,
Left sided CHF with
pulm edema, CAD
and angina
American Dream Review
Institute Inc.
11
Landmarks
American Dream Review
Institute Inc.
12
Cardiac
9. Neck Veins
Patient at 45 degree angle ( )
Neck Veins Flat ( ) Distended ( )
10.Heart Tones
Apical Pulse with Stethoscope
Rate ?_____________
Rhythm ? ___________
Clarity of Sounds ? _________ Abnormal ? ( )
Explain ! ____________________________
13
Heart Tones
Heart tones are checked by
listening to the apical pulse.
This pulse is auscultated with the
bell of the stethoscope.
Check the apical pulse for rate,
rhythm, and clarity of the
sounds of the S1 and S2
otherwise known as "lub and
dub".
Any abnormalities should be
reported.
Heart Sounds
Heart sounds result from the vibrations from
closure of the heart valves and the
acceleration and deceleration of blood flow.
• S1 - the lub sound that represents closure
of the tricuspid and mitral valves. Heard
best at the apex.
• S2 - the dub sound. This represents closure
of the aortic and pulmonic valves. It is the
onset of ventricular diastole and is heard
best at the aortic area.
• S1 split - a slight difference in valve closure
timing. This is a normal variation heard best
at the right 4th intercostals space.
Heart Sounds
•
•
S2 split - this is a splitting of the dub, or the second sound.
Heard best during inspiration at the pulmonic area. Usually
disappears in the sitting position
S3 (ventricular gallop) - normal in healthy children and
young adults and is produced by vibrations of the ventricles
due to rapid distention. This may be seen in left ventricular
failure. Heard best at the apex with the patient lying on the
left side. Heard with the bell of the stethoscope and sounds
like “Kentucky”. May indicate incompetence of the mitral and
tricuspid valves.
S1 S2 S3 Ken tuck ee Lub dub dub
Heart Sounds
S4 (atrial gallop or presystolic gallop) - Heard best over the
apex with the pt in lying supine.
Indicative of increased resistance to filling and may be associated
with coronary artery disease, hypertension, aortic stenosis, or
the elderly.
This sound is heard best with the bell of the stethoscope over the
left lower sternal border. It sounds like “Tennessee”.
S4 S1 S2 Ten ne see Dub lub dub
Heart Sounds
Classifications
– Diastolic Murmurs - occur
between S2 and S1. Seen
in mitral or tricuspid
stenosis, aortic or pulmonic
insufficiency.
– Systolic murmurs - occur
between S1 and S2. Seen
in aortic or pulmonic
stenosis or mitral or
tricuspid insufficiency. They
are also called holosystolic
or parasystolic murmurs.
Heart Sounds
Heart Murmurs - are caused by
increased flow through normal
structures.
Areas for Auscultation
Mitral murmurs are heard best with the
patient in the left lateral position.
Aortic murmurs are heard best with
the patient sitting and leaning forward
after complete exhalation.
American Dream Review
Institute Inc.
Cardiac
11. Bilateral Checks
•
•
•
•
( Radial Pulses ) - Rate, Strength, Regularity
Right_____________ Left______________
( Hand Strength ) - 2 fingers only
Right Stronger ( ) Left Stronger ( ) Equal ( )
( Pedal Pulses – DP/PT ) - Top of Foot
Right Foot __________ Left Foot ____________
( Capillary Refill ) - On fingers or toes 3 seconds or less
Right Fingers ( ) sec. Left Fingers ( ) sec.
Right Toes ( ) sec. Left Toes ( ) sec.
American Dream Review
Institute Inc.
20
Mr. Baga
Mr. Baga, 70 y/o
chronic COPD of Dr.
Dy, admitted for
dyspnea episode 2
days ago
21
Landmarks
American Dream Review
Institute Inc.
22
Pulmonary Assessment
Pulmonary
12. Breath Sounds
•
•
•
•
•
•
Assess anterior and posterior and from side to side, left
to right lobe.
Have patient take deep breaths, do not move
stethoscope to rapidly to avoid hyperventilating on
patients part.
Clear Bilaterally ( ) Left only ( ) Right only ( )
diminished, tight bilaterally ( )
Crackles or Rales, Fine or Coarse Crackles, Rhonchi
Good air flow ( ) Poor air flow ( )
ICSP __________
American Dream Review
Institute Inc.
24
Breath Sounds
The diaphragm of the stethoscope is
used for assessing breath sounds.
The right middle lobe is assessed by
listening on the patient's right
side.
Have the patient take deep breaths in
and out of their mouth.
Nose breathing can create air
turbulence that may alter the
sounds.
Breath sounds should be clear
bilaterally with good air flow.
American Dream Review
Institute Inc.
Breath Sounds
Normal breath sounds
– Bronchial sounds - Pitch: High. Intensity: Loud,
predominantly on expiration. Normal findings: A sound
like air blown through a hollow tube
– Bronchovesicular sounds - Pitch: Moderate.
Intensity: Moderate. Normal findings: A blowing sound
heard over airways on either side of sternum, at angle
of Louis, and between scapulae
– Vesicular sounds - Pitch: High on inspiration, low on
expiration. Intensity: Loud on inspiration, soft to
absent on expiration. Normal findings: Quiet, rustling
sounds, heard over periphery
American Dream Review
Institute Inc.
Breath Sounds
Abnormal breath sounds - diminished, distant or tight
– Bronchial sounds - Pitch: High. Intensity: Loud, predominantly
on expiration. Normal findings: A sound like air blown through a
hollow tube
– Bronchovesicular sounds - Pitch: Moderate. Intensity:
Moderate. Normal findings: A blowing sound heard over airways
on either side of sternum, at angle of Louis, and between
scapulae
– Vesicular sounds - Pitch: High on inspiration, low on expiration.
Intensity: Loud on inspiration, soft to absent on expiration.
Normal findings: Quiet, rustling sounds, heard over periphery
American Dream Review
Institute Inc.
Breath Sounds
ADVENTITIOUS SOUNDS
• Crackles (Rales)
Where to auscultate: Over lung fields and airways; heard in
lung bases first with pulmonary edema
Timing:More obvious during inspiration
Cause: Moisture, especially in small airways and alveoli
Description: Light crackling, bubbling; nonmusical
• Rhonchi (Gurgles) and Coarse Crackles
Where to auscultate: Over larger airways
Timing: More pronounced during expiration
Cause: Airways narrowed by bronchospasm or secretions
Description: Coarse rattling, usually louder and lowerpitched than crackles; described as sonorous, musical.
Rhonchi typically clears with coughing.
Breath Sounds
• Wheezes
Where to auscultate: Over lung fields and airways
Timing: Inspiration or expiration
Cause: Airways narrowed by bronchospasm
Description: described as sonorous, musical, or sibilant
Creaking, Whistling; high-pitched, musical squeaks
• Pleural Friction Rub
Where to auscultate: Front and side of the lung field
Timing: Inspiration
Cause: Inflamed parietal and visceral pleural surfaces
rubbing together.
Description: Grating or squeaking
Neck Veins
Neck veins should be checked by
having the patient sit at a 45
degree angle. In this position,
the jugular veins should be
flat.
Distended neck veins at 45
degrees are an indicator of
over hydration or fluid
overload.
American Dream Review
Institute Inc.
Mrs. Tiyan
Mrs. Tiyan, 45 y/o s/p
exploratory laparotomy of
Dr. Espiritu, yesterday
afternoon
American Dream Review
Institute Inc.
31
Gastro-intestinal
13. Bowel Sounds
•
•
•
•
•
•
•
7/16/2015
Assess all 4 quadrants, do not touch stomach before
auscultation, as it may disrupt normal sounds. If
irregular,
1 minute assessment on each quadrant. Umbilicus is
mid point.
( Stomach ) - Check for condition
Soft ( ) Hard ( ) Distended ( ) Other
RUQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )
RLQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )
LUQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )
LLQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )
Free Template from www.brainybetty.com
34
Mr. Bahag-Hari
Waiting for new admission
from PACU – Mr.
Bahag-Hari, s/p
suprapubic
prostatectomy of Dr. Sy.
American Dream Review
Institute Inc.
35
Genito-Urinary
Genito-urinary
14. Ask the patient
Urgency, Burning, Incontinence, pain
15.Assess
Catheter, Drainage, Urine output
37
Mrs. Asukar
Mrs. Asukar, 65 y/o female
patient of Dr. Tormes,
long-term Type I
diabetic, admitted for
episode of hypoglycemia
yesterday
38
Integumentary
16. Skin
•
•
•
Skin Turgor - 1 to 3 second return, on Sternum
Return was ( ) sec. Abnormal ( ) sec.
Skin Color - Check on inside of Lip or Conjunctiva
Lip ( ) Conjunctiva ( )
Pink ( ) Pale ( ) Jaundice ( ) Cyanotic ( )
Skin Temperature - Use back of hand to check
Hot ( ) Warm ( ) Cool ( )
American Dream Review
Institute Inc.
39
Braden Scale
17. Skin Breakdown Check
40
Peripheral Edema
Edema, or fluid in the tissues tends
to go to dependent areas of the
body. This may be the hands,
feet or sacrum.
For the bed rest patient, the
dependent area is most often
the sacrum.
To check for edema push your
finger down on the feet, hands,
and sacrum. Observe for
indentation or pitting.
American Dream Review
Institute Inc.
ASSESSMENT SCALE FOR
PITTING EDEMA
1+ slight pitting, no visible distortion, disappears
rapidly
2+ somewhat deeper pit than 1+, no readily detectable
distortion, disappears in 10-15 sec.
3+ pit noticeably deep, may last more than a minute;
the dependent extremity looks fuller and swollen.
4+ pit very deep, lasts 2-5 min; dependent extremity is
grossly distorted.
Vascular
18.Peripheral Edema
•
•
Edema is found in dependent areas such as the feet,
hands, sacrum. Check with finger by pressing down.
Observe for pitting or indentation.
Feet Yes ( ) No ( ) Pitting ( ) R ( ) L ( )
Hands Yes ( ) No ( ) Pitting ( ) R ( ) L ( )
Sacrum Yes ( ) No ( ) Pitting ( ) Indent
19. Distal Pulses
•
•
•
Dorsalis Pedi and Post Tibial
Palpable or dopplerable
Arterial or venous
44
Post Tibial
Dorsalis Pedis
45
Vascular
20.Homan's Sign
Ask patient to dorsiflex both feet.
Pain in right calf Yes ( ) No ( )
Pain in both calves Yes ( ) No ( )
46
Pain Assessent
21. Assessing For Pain (PQRST method)
P – Provokes, palliative measure
Q – Quality (describe)
R – Region, radiate?
S – Severity, on a scale of 0 - 10
T – timing, when did it start? How long does it last?
47
Psychosocial
22. Psychosocial Aspects
• Affect of illness on role such as work, family
• Inappropriate independence, dependence?
• Check for depression, suicidal ideation if
needed.
American Dream Review
Institute Inc.
48
Education Assessment
23.Response to learning
Learning barriers
49
Closure
24. Closure
Let the patient know you are finished and
when you will be back.
• Bedrails up ( )
• Bed in low position ( )
• Call light in reach ( )
50
7/16/2015
Free Template from www.brainybetty.com
51
Q
and
A
IT’S
SHOWTIME!
American Dream Review
Institute Inc.
53