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Equip required to perform nut-focused physical assessment
Stethoscope, wooden tongue depressor, gloves, pen, penlight, skinfold calipers, something for pt to smell
4 basic techniques used & order. What is order when the abdomen is being asssessed?
- Inspection, palpation, percussion, auscultation
- Assessment of abdomen: do auscultation first, then the rest
Clubbing of nails in which they curve down is associated with:
chronic long term lung disease (from poor oxygenation)
Spoon-shaped nail that curves upward:
Cranial nerve used to evaluate smell, and how level of functioning of this nerve could be determined
olfactory nerve; present diff odors
How to test for skin turgor and state its significance
- Assess degree of hydration; pinch fold of skin and see if it stays pinched or goes right back; malnourished, dehydration, or wt loss
- -Grasp the skin on the back of the hand, lower arm, or abdomen between two fingers so that it is tented up. The skin is held for a few seconds then released.
- -Skin with normal turgor snaps rapidly back to its normal position. Skin with decreased turgor remains elevated and returns slowly to its normal position.
- -Decreased skin turgor is a late sign in dehydration. It occurs with moderate to severe dehydration.
Medical conditions in which you would be likely to find peripheral edema
- Low albumin (causes fluid to leak out of cell and into interstitial fluid)
Identify method used to determine capillary refill time
- Push on nail bed and watch how long takes to turn red again. Normal refill time is less than 2 seconds.
- Indication of dehydration.
- -Poor circulation, usually CAD
State significance of jugular venous distention (JVD)
may indicate CHF (heart pumps harder) (if so, pt may need fluid restriction)
Identify areas of body in which pressure ulcers (decurbitus ulcers) are likely to be found
Bony prominences or other areas that stick out, such as ears, bk of neck, elbows, tailbone, heels, etc
How would you monitor your patient’s tolerance to tube
- GI symptoms: abdominal distention or pain, diarrhea,
- Fasting glucose
- Urine volume
- Serum Na
- Gastric residuals (if on G-tube)
How would you monitor how effective your tube feeding is in
meeting nutritional needs?
- Weight change
- Nitrogen Balance
What is the purpose of the general
survey segment of the assessment?
- To get an overall impression of
Identify the cranial nerve used to
evaluate sense of smell, and how you would assess this:
- Use vanilla/cinnamon: blind fold patient and cover a nostril, ask them to identify the smell. Repeat with other nostril and a different flavor
What is the significance of
finding a deviated nasal septum
if tube feeding is possible, or which side to place tube