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Types of nursing assesments
initial, focused, shift, emergency, ongoing
- comprehensive assessment
- done with the first/initial contact with pt to rule out and identify problems
- detailed exam of the identified problem areas.
- done with new complaints and problems identified
- combo of initial and focused exam.
- done at the start of a shift or change of care providers.
- life threatening or time sensitive.
- prioritized based upon ABC
- throughout pt stay
- before and after interventions
- 36-38 deg C
- 96.8-100.4 deg F
60-100 beats per min
12-20 breaths per min
O2 Saturation SpO2
90% (really want it to be 95%)
- Pain rating scale: Faces and number rating scale
- P: provoke- what makes it better/worse
- Q: quality
- R: radiation
- S: severity
- T: temporal factors
Visual exam. symmetry is key
- Touch to examine body
- back of hand: temp
- fingertips: texture, shape, size, consistency, position and tugor.
- Palm: vibration
- short, sharp strikes or tapping on body to produce vibrations and sounds to evaluate size, borders, and consistency of body organs.
- Fluid filled: melon
- air filled: drum
- solid: wood
- listen to sounds made by the lungs heart and intestines.
- intensity(loudness), frequency, quality(gurgling), duration(length)
abdominal physical assessment
- inspect, auscultation, palpate, percussion
- This is because if you tap before listening, you can hear can air bubbles in the intestines not bowel sounds.