Who spends the most time with the client, knows the most about the client, and is able to communicate the client's needs to the rest of the health care team the most effectively?
What are the 3 areas of assessment the nurse focuses on in order to get a complete picture of the client?
Body: assess the physical systems
Mind: assess psychosocial health
Spirit: assess for religious or spiritual beliefs
What is the nursing process?
- Assess: gather data
- Diagnosis: client problems that are based on medical diagnosis
- Plan: goals
- Implement: interventions
- Evaluate: how the client responded to the intervention
The nursing process is not linear. The nurse will jump back and forth between the steps depending on additional data acquired about the client.
What are nursing clinical judgment skills?
Nursing clinical judgment skills are:
- understanding WHY an intervention is done
- prioritizing what is important
- interpreting sign and symptom data
- gathering more information if there is not enough to make an informed decision
When does teaching and discharge planning by the nurse begin with a client?
Teaching and discharge planning can begin during the assessment even while the client is being admitted.
During the admission assessment data is gathered by the nurse such as home environment and available resources so that teaching can begin right away, if there are needs.
What are the two purposes of doing a nursing assessment on a client?
The purpose of doing a nursing assessment is to:
- gather data (especially abnormal data) about the client to heal the client or prevent them from getting sick.
- notify the health care provider (HCP) of immediate complications or changes in the client's condition in order to update the care plan.
The HCP can be a doctor, nurse practitioner or physician assistant.
What is the typical assessment order for most body systems?
The typical body assessment order is:
What is the difference between a focused health assessment and a comprehensive health assessment?
- A focused health assessment focuses on the immediate concern and is done when the client has a specific complaint or immediate information is needed.
- A comprehensive health assessment is when the nurse assesses the entire client head to toe.
Which main physical systems are assessed in a comprehensive assessment starting from head to toe?
The main systems assessed are:
In addition to the physical assessment of the client, what additional data does the nurse look at to get an overall picture of the client?
Look at the following to get an overall picture of the client:
- CBC, BMP or CMP
- labs specific to problem
imaging diagnostic tests
- x-rays, CT scan, MRI, etc
- medical and surgical history and physical from HCP
- medication record
How often should a typical nursing physical assessment be done on each of the following units:
- Progressive or Step-down unit
- Medical-surgical unit
Post-Op: focused assessments every 5- 15 minutes
ICU: about every 1-2 hours
Progressive or Step-down unit: about every 2-4 hours
Medical-surgical unit: about every 4-8 hours
What is subjective and objective data?
Subjective data is what the client tells you
- example: the client's stated pain level
Objective data is what anyone can observe
- example: a set of vital signs
Posterior and Anterior
Posterior means the back of something
Anterior means the front of something
Distal and Proximal
Distal means away from something
Proximal means closer to something
What is a very quick and basic neuro assessment?
Assess the level of consciousness by asking the client 4 questions:
- Person: What is your name?
- Place: Where are you?
- Time: What year is it? or Who is the president?
- Situation: Do you remember why you are here?
What is PERRLA?
PERRLA is using a light to check if pupils are:
- React to Light
- Accommodate (pupils constrict as objects get closer)
What is the cranial nerves "saying" in order to remember the names of the 12 cranial nerves?
Oh, Oh, Oh! To Touch And Feel A Good Velvet, Such Heaven!
- Spinal Accessory
Draw the cranial nerve face.
This will help you to remember the function and location of the nerves.
What is the function of cranial nerve I?
I. Olfactory: smell
What is the function of cranial nerve II?
II. Optic: vision
What is the function of cranial nerve III?
III. Oculomotor: movement of pupils and eyelids
What is the function of cranial nerve IV?
IV. Trochlear: downward and inward movement of the eyes
What is the function of cranial nerve V?
V. Trigeminal: chewing
What is the function of cranial nerve VI?
VI. Abducens: eye movement lateral (side to side)
What is the function of cranial nerve VII?
VII. Facial: movement of all the facial muscles and taste
What is the function of cranial nerve VIII?
VIII. Acoustic/Vestibulocochlear: hearing
What is the function of cranial nerve IX?
IX. Glossopharyngeal: swallowing and taste
What is the function of cranial nerve X?
X. Vagus: swallowing and speaking
What is the function of cranial nerve XI?
XI. Spinal Accessory: shoulder movement
What is the function of cranial nerve XII?
XII. Hypoglossal: tongue strength
What are the 4 areas of the brain?
The 4 areas of the brain are:
- frontal lobe
- parietal lobe
- temporal lobe
- occipital lobe
What is the function of the frontal lobe?
Frontal lobe: controls thinking and personality changes
What is the function of the parietal lobe?
Parietal lobe: processes information for temperature, taste, and movement
What is the function of the temporal lobe?
Temporal lobe: controls hearing, language comprehension, and memories
What is the function of the occipital lobe?
Occipital lobe: controls vision
What are the 4 regions of the spine?
Sacral and Coccyx: S1-S5
What do the cervical nerves control?
Cervical: C1-C8: nerves control breathing, arm, and neck movement.
What do the thoracic nerves control?
Thoracic: T1-T12: nerves control chest, back, and abdomen strength.
What do the lumbar nerves control?
Lumbar: L1-L5: nerves control lower abdomen, buttock and leg strength.
What do the sacral and coccyx nerves control?
Sacral and Coccyx: S1-S5: nerves control thighs, lower leg strength, and genitals.
What questions are asked during a nursing lung assessment?
During a nursing lung assessment, ask the client:
- Have you had any difficulty breathing at rest or with activity?
- Have you had a cough?
- If so, is it dry or a productive cough with mucus?
- If productive with mucus, what color is it?
What are the normal lung sounds?
The normal lung sounds are:
- Bronchial (tracheal)
Where is the stethoscope placed when doing a nursing lung assessment?
Place the stethoscope at the top and go progressively down the anterior and posterior thorax.
Adventitious lung sounds
Abnormal breath sounds
What are diminished or absent breath sounds?
An area of the lungs where the movement of air cannot be heard.
dyspnea, tachypnea, and bradypnea
dyspnea: difficulty breathing
tachypnea: rapid respirations > 20
bradypnea: slow respirations < 12
What is the difference between fine, medium, and coarse lung crackles?
Crackles are lung sounds caused by fluid in the lungs.
What are wheezes?
Wheezes are high squeaky lung sounds.
They are caused by the small airways narrowing, usually in asthma. Click HERE for an audio sample.
What are rhonchi?
Rhonchi are low-pitched lungs sounds that resemble snoring.
It is caused by secretions in the airway. They may clear with cough. Click HERE for an audio sample.
What is atelectasis?
Atelectasis is incomplete expansion of the lung that causes diminished breath sounds.
It is most common with pneumonia.
What is a pleural friction rub?
Pleural friction rub is a low-pitched grating sound from pleurisy (inflammation in the lungs).
Click HERE for an audio sample.
What is included in a basic nursing cardiac assessment?
A basic nursing cardiac assessment includes:
- asking the client about chest pain or chest discomfort
- listening to heart sounds
- checking pulses
- checking capillary refill
- checking skin temperature and color
- checking for edema and skin turgor
- assessing cardiac rhythm strip
Brady and Tachy
Brady means slow
Tachy means fast
Bradycardia means a heart rate < 60
Tachycardia means a heart rate >100
Where are the 5 heart sounds located?
- aortic, pulmonic, Erb's point, tricuspid, mitral
Use the mnemonic: "APE To Man" to remember.
What are the heart sounds S1 and S2?
S1 and S2 are the normal heart sounds. It is sometimes known as "lub dub".
Click HERE for an audio sample.
What are the heart sounds S3 and S4?
What is a heart murmur?
A heart murmur is an abnormal heart sound other than "lub-dub". It can be a whooshing, swishing or clicking noise.
Click HERE for an audio sample.
Label the pulses on the diagram from the following choices:
- brachial, carotid, dorsalis pedis, femoral, posterior tibial, radial, ulna, popliteal
What are the 4 pulse strengths and what do they indicate?
Pulse strengths are:
- 4+: strong and bounding - indicates fluid volume overload
- 3+: full pulse - less severe fluid volume overload
- 2+: normal - easily palpable
- 1+: weak, barely palpable - indicates fluid volume deficit
What is edema and pitting edema and how is it assessed?
Edema is too much fluid in the body. It can be localized or throughout the body.
Pitting edema is when the skin remains indented after pressing with a finger.
- 1+, 2mm: a small pit and rebounds in a few seconds
- 2+, 4mm: a medium pit and rebounds in a few seconds
- 3+, 6mm: a deep pit and rebounds in 10-20 seconds
- 4+, 8mm: very severe edema and rebounds in >30 seconds
What is anasarca?
Anasarca is another word for generalized edema.
What is skin turgor and how is it assessed?
Skin turgor is assessing the client's fluid status by pinching a fold of skin.
- If the skin tents up, it indicates dehydration or fluid volume deficit.
- if the skin returns to the normal position, there is no fluid issue
How is capillary refill assessed?
Capillary refill is assessed by pressing down on the nail bed.
- if the pink color comes back in < 3 seconds, that is normal.
- if the pink color comes back in > 3 seconds, it is abnormal.
Cap refill assesses the client's blood circulation.
Label the gastrointestinal organs on the diagram from the following choices:
- appendix, esophagus, gallbladder, large intestine, liver, pancreas, rectum, small intestine, stomach
What does a basic nursing gastrointestinal assessment include?
The basic nursing abdominal assessment includes:
- listening to bowel sounds
- ask when last bowel movement was
- ask if passing gas
- ask if patient experiences nausea/vomiting
- determining appetite
What is the unique nursing assessment order for the abdomen/GI?
Nursing assessment order for abdomen/GI:
It is done from least to most invasive in order to not disturb the abdomen and cause inaccurate findings.
What are the four areas of the abdomen and how long is each quadrant listened to before deciding if there are bowel sounds?
Listen to each quadrant for 5 minutes = a total of 20 minutes
- start at upper left, upper right, lower right, lower left
- go in a counterclockwise direction
What are the different types of bowel sounds?
The types of bowel sounds are:
- absent: no bowel sounds
- hypoactive: 1 sound every 3-5 minutes
- normal: 5-30 clicks or gurgles per minute
- hyperactive: > 30 sounds per minute or an increase from the client's baseline
How is the body mass index (BMI) calculated?
BMI = kg ÷ m2
- normal weight = 18.5 to < 25
- overweight = 25 to < 30
- obese = > 30
Example: if a client weighs 70 kg and is 1.8 meters tall, the BMI is 70 ÷ 1.82 = 21.6
NPO means nothing by mouth.
Don't allow the client to eat or drink anything. This is a common order for preventing aspiration during surgeries and procedures or when having an acute GI issue.
What are the 2 main functions of the pancreas?
Function of the pancreas:
- endocrine organ: to release insulin so the body can regulate glucose/sugar
- exocrine organ: to release enzymes for food digestion
What is the function of the gallbladder?
The function of the gallbladder is to store bile that's made by the liver for food digestion.
What are the 4 main functions of the liver?
The 4 main functions of the liver are:
- to make clotting factors to prevent bleeding
- to make proteins so all the organs and cells can function
- to metabolize toxins and cholesterol
- to make bile for digestion
What does a basic renal/urinary assessment include?
A basic renal/urinary assessment includes:
- checking urine output and color
- monitoring intake and output
- checking labs: BUN, creatinine, GFR, electrolytes
What is the minimum urine output for an adult and newborn?
Minimum urine output:
- adult: at least 30 mL/hour
- infant (up to 1 year): at least 2ml/kg/hour
What does a basic nursing musculoskeletal assessment include?
A basic nursing musculoskeletal assessment includes:
- checking muscle strength and range of motion
- asking about pain, numbness, and tingling
- checking electrolytes and other labs
- imaging tests for the spine and head
What are the assigned numbers for muscle strength?
- 0 is no muscle strength
- 5 is normal muscle strength
Label the bones on the diagram from the following:
- cranium, femur, fibula, humerus, patella, pelvis, radius, ribs, scapula, sternum, talus, tibia, ulna, vertebra
What is kyphosis?
Kyphosis is a curved thoracic spine (hunchback).
It is common in the elderly with osteoporosis.
What is scoliosis?
Scoliosis is lateral spine curvature.
It is tested in teenagers.
What does a basic nursing skin assessment include?
A basic nursing skin assessment includes:
- skin color
- wounds (especially on bony areas)
- abnormal moles/freckles
- asking about new meds or exposure to infectious diseases
- many cause rashes
urticaria and pruritis
- urticaria: hives
- pruritis: itching
Cyanosis is when the skin has a blue tint due to a low oxygen reading.
How is cyanosis assessed in a dark-skinned client?
Look for a bluish color by checking lips, tongue, nail beds, palm soles, and conjunctiva.
Erythema is redness of the skin.
It indicates injury, inflammation or infection.
Pallor is skin that is lighter than what the client is normally.
It can indicate decreased blood flow.
Jaundice is yellowing of the skin, mucous membranes, and whites of the eyes.
It indicates liver failure.
Ecchymosis is bruising of the skin.
What questions are asked for a nursing pain assessment?
Nursing pain assessment questions are:
- Location: where is the pain?
- Severity: how bad is it? Use appropriate pain scale.
- Character: what does it feel like?
- Onset: when did it begin?
- Associated factors: are there other symptoms that occur with it?
- Pattern: what makes it better? what makes it worse?
- What pain meds do you take?
- Do you use alternative therapies to manage pain?
What are basic documentation guidelines for nursing?
Nursing documentation guidelines are:
- use black ink
- date/time/name on each entry
- document right after activity
- be factual
- use quotes for subjective data
- document refusals of treatments and calls to HCP
How should an error be documented in a client's medical chart?
Draw one line through the error, initial and date.
What is unacceptable for nursing documentation?
Unacceptable documentation for nursing:
- do NOT document for others
- do NOT leave blank spaces on forms
- do NOT use unacceptable abbreviations