When doing a complete assessment on a client, the nurse must analyze findings to do what?
Hello future nurses! Here is an outline of how to conduct a complete head to toe assessment. Included in this outline are some tips that will help you develop a routine and gain confidence when assessing your patients. Let's get started! Show
As soon as you walk into the exam room the assessment begins.The nurse should note:
These initial assessments are essential when assessing a patient’s mental status. During this time, you should also obtain subjective data from the patient to have a better understanding of why they are in the office. You can do this by asking how they are feeling or ask what they are in the doctor's office for today. 2. Vital Signs After taking the time to speak with the patient, ask permission to collect their vital signs. Collecting vitals allows you to comfortably approach the patient with touch for the first time during the interview. TIP: Remember to ALWAYS ask permission before touching the patient and explain each one of the assessments you will be performing. 3. Hair/Skin/Nails When performing assessments on different areas of the body (ex. abdomen, arms, or legs), you should note abnormal findings of the skin and hair on these areas. The nurse should assess nails for:
Abnormal findings include: Uneven hair distribution, color abnormalities (Pallor, Cyanosis, Erythema), extremes in temperature or moisture of skin, decreased skin turgor, lesions 4. Head
Abnormal findings include: Tenderness, swelling, asymmetry 5. Neck
Abnormal findings include: Deviation of the trachea, enlarged thyroid gland or lymph nodes 6. Eyes
Abnormal findings include: Discharge, lesions, redness, no PERRLA 7. Nose and Sinuses
Abnormal findings include: Deviated septum, nasal polyps, discharge 8. Ears
Abnormal findings include: Discharge, lesions, abnormal light reflection on tympanic membrane, scarring of the tympanic membrane. 9. Mouth and Throat
Abnormal findings include: Swelling, asymmetry, lesions, cyanosis, dry/cracked lips, cleft lip, discoloration, dryness, hairy tongue, enlarged tonsils, cleft palate. 10. Chest (Cardiovascular and Respiratory) Cardiovascular
Abnormal findings include:Pericardial friction rub, murmur, presence of S3 or S4, irregular heart beat. Respiratory
Abnormal Findings include: Retraction, labored breathing, asymmetrical chest expansionRetraction, gasping for air, Bradypnea or Tachypnea, absent lung sounds, crackles, wheezes, Stridor, and Pleural friction rub. 11. Abdomen
Abnormal findings include: Abnormal pulsations, Hypo/Hyperactive Bowel sounds, purple or dark red skin pigmentation, tenderness, mass/protrusion. 12. Peripheral Vascular
Abnormal findings include: Delayed capillary refill, bounding or absent pulses, presence of Arterial or Venous Disease, skin discolorations. 13. Neurological & Musculoskeletal
Abnormal findings include: Crepitus, swelling , pain/tenderness, limited or no range of motion, hyperactive response, pain, tenderness, no response, hyperactive response. If the tap triggers a repeated tendon reflex: Assess Balance - Romberg test; Assess Gait by having the patient walk across the room and walk back towards you in a straight line, heel to toe. 14. Assessment Conclusion
15. Practice…Practice…Practice
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Now that you are confident and prepared... Get out there and assess those patients! You’ve got this! What do you do when assessing a patient?WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation. Use them in sequence—unless you're performing an abdominal assessment. Palpation and percussion can alter bowel sounds, so you'd inspect, auscultate, percuss, then palpate an abdomen.
What are the steps of nursing assessment?The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.
What are the 5 steps in the patient assessment sequence?The steps are as follows:. Assessment phase.. Diagnosis phase.. Planning phase.. Implementing phase.. Evaluation phase.. Which assessment should the nurse complete first?A thorough medical history and physical assessment will be useful but is not the first action the nurse must take. The physician should be notified but the nurse must assess vital signs first.
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