NP5 Physical Assessment

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NP5 Physical Assessment

• Skills, Knowledge and Transfer

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Principles of Assessment Decision Making

• Know why you are gathering data
• If you are not going to address a problem if you
  find it, dont look!

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Principles of Assessment Decision Making

• Baseline shift assessment should take no more
  than 3-4 minutes. Greater than 4 minutes only if
  the patient is agitated or has difficulty moving

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Principles of Assessment Decision Making

• What is likely to change with this patient?
• How rapidly will/may something change?

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Principles of Assessment Decision Making

• What will my patient (and all my other patients)
  experience if I make the wrong decisions?

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What can be assessed without DIRECT assessment

• Neurological
• LOC by conversation
• Strength and movement by ADLs

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What can be assessed with without DIRECT
assessment

• Cardio-Vascular
• Capillary Refill by checking vital signs and/or
  pulse
• Temperature/moisture by checking vital signs
  and/or pulse
• Turgor/edema by checking vital signs and/or pulse

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What can be assessed without DIRECT assessment

• Pulmonary
• Respiratory rate and rhythm, tidal volume and
  respiratory effort by conversation

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What can be assessed without DIRECT assessment

• GI
• GI function by calls for help to BR
• Appetite

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• Your 65 year old CVA patient does not respond
  spontaneously when you walk into the room and
  speak to her in a fairly loud voice. You have
  done two levels of stimulation, visual and
  verbal. Explain the nursing assessment actions
  that reflect 3 increasingly forms of stimulation
  done at the next level by the nurse to elicit a
  response from this patient.

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Answer

• Touch-light
• Touch-deep
• Touch-pain

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• Your 45 year old patient has had a Lap Chole and
  is immediately post-op after 12 hours NPO in
  surgery. You additionally hear that he has a
  history of Myasthenia Gravis. What is your
  priority assessment for this patient ?

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Answer

• Assess ability to swallow and manage own
  secretions
• Check for order of Mestinon (cholinesterase drug)
• Get prompt orders and delivery of drug before
  airway management becomes a problem

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• Your 50 year old cardiac cath patient has
  returned to the telemetry unit with a sheath in
  their right groin. What are at least 6 essential
  assessment observations the nurse will make to
  ascertain the clients status?

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Answer

• Site observation for bleeding
• Peripheral pulse distal to the right groin
• Blood pressure
• Pulse
• Temperature
• PTT and PT times

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Non-Direct Assessment

• You have just completed a conversation with your
  69 year old client with prostate cancer. He
  speaks about the breaking news on TV and he asks
  you about lunch (it is noon) and that he is
  hungry. You help him to the BR he shows improved
  OOB exercise tolerance and steady gait. What
  systems/areas have you just assessed by
  observation?

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Answer

• Neuro-strength and movement
• Cardio-Pulmonary- exercise tolerance
• Cognition
• GI/GU-continency

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Importance of time frames

• Knowing what to expect at certain reasonable time
  frames of a post-op course for your patient helps
  the nurse interpret data accurately and plan the
  next choice of observation and time-cycle of
  assessment

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Scenario

• Your 25 yr patient has had an exploratory LAP for
  Ca of the colon. He acts like nothing has
  happened and does not ask any questions about the
  outcomes of the surgery. He is 15 hours post op
  and there are no bowel sounds. His abdomen is
  slightly swollen and tender to light touch. The
  NG is to low suction and it drained 300 cc of
  green brown fluid. The night RN said that there
  were bowel sounds

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• What may have happened in the night shift nurses
  behavior that might make her/his bowel sound
  assessment inaccurate?

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Answer

• Possibly listened with the NG suction on and the
  heard the sounds of the intermittent suction

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• When might we expect this patient to have a
  return of bowel sounds?
• 24 hours
• 48 hours
• 72 hours

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• The patient has a slightly swollen and tender to
  light touch abdomen. What is your conclusion of
  these findings?

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How frequently will you

• Take his vital signs?
• Assess his abdomen
• Assess pain

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• What is going on with this patient from a
  psycho-social perspective?
• What is going on with his apparent lack of
  concern, absence of questions about his condition?

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• How might you plan to approach this client in
  this stage of the cancer diagnosis?
• When will you expect him to show concern and ask
  questions?

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Repeat assessments in the shift

• How often you repeat observations and assessments
  during a 12 hour shift takes judgment based upon
  client age, growth and development, diagnoses,
  report of previous shift and condition at this
  time.

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Scenario

• Second day of admission
• Hx Type II diabetes, HTN, blind in R eye
• Fever last night of 102 medicated to 100 now
• IV antibiotics q12 hour
• Foley output last 12 hours is 300

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• What is the frequency of your blood pressures?

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• How often will you assess the temperature?

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• What assessment might you need an order for to be
  done four times a day?

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• The urine output does not meet a normal
  parameter.
• What is this parameter?
• What are your follow up assessments?

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Multiple patients and priority baseline
assessments

• Importance of selecting key base line assessments
  to complete when first meeting a patient
• These priority assessments are based on
  pathophysiology, expected clinical conditions and
  individual presentation

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• How will you direct the unlicensed nursing
  personnel for ADLs?

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Scenario

• 56 year old male
• Dx R/O acute MI
• Admitted 4 hours ago
• Hx HTN, asthma since childhood (stable)
• Key assessments now
• Key assessments 24 hours later with no MI and
  being discharged this shift?

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Scenario

• 71 year old female
• Dx Fem Pop-bypass 1 day post op
• Hx No chronic diseases
• Report some pain, not well relieved
• Key assessments now
• Key assessments at 48 hours with discharge pending

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Scenario

• 65 year old female admitted last night
• Dx Pneumonia
• Hx No chronic diseases
• Report some lethargy, SOB when moves around in
  bed, pulse ox _at_ 94, O2 2LPM via NC, afebrile
  now, admit 100.2 orally

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Frequency of assessments

• Pulmonary
• VS
• CV
• LOC
• 36 hours later-OOB, no O2, pulse ox 97

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Scenario

• 47 year old male, MVA early AM admit from ER
• Left sided fractures clavicle, 2 ribs, humerous
  with broken teeth and mouth guard in place
• Hx ETOH quart a day of vodka-does not believe in
  doctors
• Report Not very stable P 112,BP 160/90, pulse ox
  94, O2 4LPM via NC, pain well relieved with MS

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Frequency of assessments now and when stable

• Neurological
• Cardio-Vascular
• Pulses
• GI
• GU
• MS
• VS
• Pain
• Important labs

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Scenario

• 26 year old male admitted to floor 20 minutes ago
  from ER
• Dx S/P grand mal seizure (first occurrence) R/O
  head injury
• Hx Some experimentation with street drugs, no
  chronic disease
• Report Tox screen negative, sleepy/groggy,respond
  s to loud verbal stimuli, vs stable, incontinent
  of urine immediately after seizure

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Frequency of assessments

• Neuro
• C-V
• Pulses
• GI/GU
• VS
• Pain
• Check for aura

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24 hours later

• Second seizure has occurred a few hours ago. CT
  is suspicious on the right parietal lobe area
• MRI is not back yet
• More alert, LOC is OK
• Left sided weakness on both arm and leg

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