Create a brochure for nurses on system-specific assessment techniques. Include t
ID: 108826 • Letter: C
Question
Create a brochure for nurses on system-specific assessment techniques. Include the correct order of assessment and the rationale behind it. Your brochure should include pictures to depict proper techniques. All references must be provided in a separate word document. Choose one of the following topics:
General surveySkin and head (i.e., this would include assessment of the eyes and ears, using Snellen chart, otoscope, performing Romberg test, testing olfaction, and so on)Chest and lungs (including pulse oximeter reading)Cardiovascular systemMusculoskeletal systemNeurological system
Explanation / Answer
There are 4 major examination techniques:
-inspection – your observations with your eyes
-palpation – what you observe and determine from touching the patient. there is light, deep and bimanual palpation
-percussion – the tapping or striking of the skin surface to elicit sound, reflexes and detect masses. there are 5 sounds of percussion that are elicited through direct, indirect or blunt percussion: tympany, resonance, hyperresonance, dullness, flatness.
The steps of the nursing process (written care plan) assessment (collect data) nursing diagnosis/analysis (group your assessment data, shop and match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use) planning (write measurable goals/outcomes and nursing interventions) implementation (initiate the care plan) evaluation (determine if goals/outcomes have been met) assessment is the first step. i think it is one of the most important. You have to collect data before you can analyze it and determine what, if any, problems you have. The styles of assessment vary. The interview and physicalexam are the most common methods used. If you go through patient charts you will see doctors using the approach of doing a (1) review of systems which includes an extensive history and (2) a physical examination by body systems. In nursing, there are several models that nurses may be asked to follow. Some nursing programs want students to assess patient using gordon's 11 functional health needs. Others use a head to toe and assessment approach. Others might use a modified gordon's assessment. In the end, however, they all are attempting to elicit the same information about the patient. They are just organizing it in a different format.
1 Assessment Techniques General Survey - Skin, Hair, and Nails
2 Cultivating Your Senses
Inspection – Always performed first
Palpation – Purpose – Use different parts of the hands – Light vs. deep palpation
3 Cultivating Your Senses, cont.
Percussion – Purpose – Direct percussion – Indirect percussion
Stationary hand • Striking hand
– Characteristics of percussion notes • Resonant • Hyperresonant • Tympany • Dull • Flat
4 Cultivating Your Senses, cont.
Auscultation – Fit and quality of stethoscope – Diaphragm and bell endpieces – Eliminate confusing artifacts
5 General Survey
Physical appearance – Age – Gender – Level of consciousness – Skin color – Facial features
Body structure – Stature – Nutrition – Symmetry – Posture – Position – Body build, contour
6 General Survey, cont.
Mobility – Gait – Range of motion
Behavior – Facial expression – Mood and affect – Speech – Dress – Personal hygiene
7 Pain Assessment Tools
Numeric rating scales – 0 is no pain, 10 is worst pain ever
Descriptor scale - – Words used to describe pain
8 Skin, Hair, and Nails
Structure and fuction
Subjective data-Health History Questions
Objective Data – ThephysicalExam
Abnormal Findings
Photos
9 Structure and Function
Skin types (3 layers) Epidermis, Dermis and Subcutaneous layer.
Epidermal Apendages – Hair, sebaceous glands, sweat glands, nails
10 Skin Structure
11 Function of skin
Subjective Data Health History Questions:
13 Objective data – The physicalExam
Preparation – External variables that influence skin color
Equipment needed – Strong direct lighting – Small centimeter ruler – Penlight – Gloves
14 Objective Data—The Physical Exam,cont.Skin—Inspect and Palpate
Color – General pigmentation – Widespread color change
Temperature – hypothermia, hyperthermia
Moisture – Diaphoresis, Dehydration
Texture
Thickness
Edema
Mobility and turgor
Vascularity or brusing
Lesion – Color, Elevation, Pattern or shape, Location and distribution, Exudate
Hair – Color, Texture, distribution, lesion
Nails – Shape and contour, consistency and color (capillary refill)
Head and Face
Assessed by inspection and palpation.
Inspect size (normocephalic); symmetry; note any deformities.
Eyes and Vision
Assessment can include external structures, ocular movement, visual fields, visual acuity and fundus.
External Structures
Eyelids: inspect for ability to blink; position (ptosis); lesions (hordeolum- stye).
Conjunctiva: palpebral (lid)- color (pink) or lesions.
Sclera: color- white, not red or yellow
Cornea: assess for opacity or scratch
Pupil: inspect for size, shape, reaction to light and accommodation. PERRLA normally, both are black, round, equal in size and react to light and accommodation. Chart is used to measure size (1-10mm). Test pupillary reaction to light: have client look at distant object (room should be dim); look for direct and consensual. Accommodation refers to pupillary change for near and distance (look far off then at finger. Eyes should converge and pupils contract).
Extraocular Movement- evaluation of the movement of the eyes while the head remains still.
8 cardinal fields of gaze, which are controlled by three cranial nerves (CN 3 oculomotor, 4 trochlear, 6 abducens). Watch for nystagmus.
Visual Fields: How much a person can see at the periphery.
Visual Acuity: Degree to which a person can discern an image. Normal is 20/20.
near vision: (general screening) have client read a paper;
far vision: (general screening) read something across the room. Do one eye; then the other. Test wearing corrective lenses.
Using Snellen Chart, have client stand 20’ from chart (numerator is 20). Take three readings, right, left, both eyes. Record the smallest line person is able to read. The denominator is the number next to the line on the chart that the person is able to read.
20/200 client can read only very large # which a person with normal vision could read at 200’. The larger the denominator, the worse the vision.
Internal Structures: Requires use of an ophthalmoscope to visualize the fundus (back part of internal eye).
The Ears
Examincludes inspection/palpation of external parts; inspection of canal and drum with otoscope and auditory acuity.
Auricle: Inspect for position (pinna level with corner of eye), compare each side; lesions.
Canal- look for drainage. Tympanic membrane (eardrum) requires use of otoscope.
Auditory acuity: gross hearing may be assessed by client’s response to voice. Test one ear at a time, covering the other. Start with a whisper. Use 2 syllable words such as “baseball.” A tuning fork may be used to perform tests such as Rinne and Weber.
The Nose and Sinuses
External nose: inspect for any deviations in shape, size, color, flaring or discharge. Check for patency Check for sense of smell (olfactory nerve- CN I).
Frontal/Maxillary sinuses- palpate for tenderness.
The Mouth and Oropharynx
Lips: inspect for color, lesions (cancer or herpes).
Oral Mucosa: Using tongue blade, inspect for color, lesions; should be uniformly pink.
Teeth (# and dentition); gums (bleeding, retraction).
Tongue: Inspect for position (center), color, and texture.
Tonsils: Lie between posterior and anterior tonsillar pillars. Normal: does not elevate above the tonsillar pillars. Should be pink and smooth; note size, hypertrophy; exudates. Should have gag reflex.
Neck:
ROM
Palpate for lymph nodes—normally cannot feel any lymph nodes; document any enlarged or painful nodes.
Jugular venous distention—refers to distention of the Jugular vein and is an indication of increased central venous pressure as found in Rt. heart failure or fluid overload. Patient should be at 30-45 degree angle and note the level of neck vein distention
References:
3-2-1 CODE IT!: 2012 UPDATE
In-text: (Google Books, 2017)
Your Bibliography: Google Books. (2017). 3-2-1 Code It!: 2012 Update. [online] Available at: https://books.google.co.in/books?id=lUwLAAAAQBAJ&pg=PA395&lpg=PA395&dq=General+surveySkin+and+head&source=bl&ots=ps8WjKqyxA&sig=tgk9zOeaWMnc6kTOvzJ8rW-qfCE&hl=en&sa=X&ved=0ahUKEwiks9mNu9_UAhUMro8KHW6XDt4Q6AEILTAD#v=onepage&q=General%20surveySkin%20and%20head&f=false [Accessed 28 Jun. 2017].
ALLNURSES | COMMUNITY FOR NURSES AND STUDENTS
In-text: (Allnurses.com, 2017)
Your Bibliography: Allnurses.com. (2017). allnurses | Community For Nurses And Students. [online] Available at: http://allnurses.com/forums/f205/hea...ms-145091.html [Accessed 28 Jun. 2017].
ESSENTIALS OF HEALTH INFORMATION MANAGEMENT: PRINCIPLES AND PRACTICES
In-text: (Google Books, 2017)
Your Bibliography: Google Books. (2017). Essentials of Health Information Management: Principles and Practices. [online] Available at: https://books.google.co.in/books?id=iVkFAAAAQBAJ&pg=PA150&lpg=PA150&dq=General+surveySkin+and+head&source=bl&ots=3En-MI_E2F&sig=7Wu_WB5YrzLGJ2GUq4beT_ro4Qg&hl=en&sa=X&ved=0ahUKEwiks9mNu9_UAhUMro8KHW6XDt4Q6AEIKTAC#v=onepage&q=General%20surveySkin%20and%20head&f=false [Accessed 28 Jun. 2017].