5 Minute Assessment

7/30/2019 5 Minute Assessment

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5 MINUTEASSESSMENT

Arthur Cantos RN, MANAmerican Dream Review

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WHY DO YOU NEEDTO PERFORMASSESSMENT

American Dream Review

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Step 1: Assessment

Complete data? Lab & x-ray?

Multidisciplinary? What is going on?What are my patients Learning needs?

Step 2: Diagnosis

Potential Problems?

Top 2 Priorities?

Two Measurable Outcomes?

Step 3: Planning

What Shall I do?

Interdisciplinary?

Resources and Timeline?

Not Just Technical Care

Involve Patient and Family?Step 4: Implementation

Am I Being Effective? Efficient?

Have I Delegated Properly?

Step 5: Evaluation

Make a Difference?Modify Plan?

Accomplish Outcomes?

THE 5 STEP

NURSING PROCESS


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Your Patients for the day

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1. Mr. Puso, 52 y/o male patient of Dr. Nerva, Leftsided CHF with pulm edema, CAD and angina

2. Mrs. Asukar, 65 y/o female patient of Dr.Tormes, long-term Type I diabetic, admitted for

episode of hypoglycemia yesterday3. Mr. Baga, 70 y/o chronic COPD of Dr. Dy,

admitted for dyspnea episode 2 days ago

4. Mrs. Tiyan, 45 y/o s/p exploratory laparotomy of

Dr. Espiritu, yesterday afternoon5. Waiting for new admission from PACU Mr.

Bahag-Hari, s/p suprapubic prostatectomy ofDr. Sy.


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LIGHTSCAMERA

ACTION

Its Showtime !!!

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INTRODUCTION

1. Knock

2. Greetings

3. Introduction

Introduce self andmembers of the team

Identification and role /

function

Purpose of assessment Provide privacy

4. Plan of Care

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Perform

5. Wash hands

6. Vital Signs

Pulse Rate, Strength, Regularity

Temperature________ Oral, Rectal, Tympanic

Respiration_______________

B / P_________

Pain Assessment _________________Oxygen saturation ________________

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Head to Toe - Neuro

7. Orientation time, person, place,

reasonWhat year is this ?

________________________

Tell me your name ?

_______________________Tell me where you are ?

____________________

Tell me why you are

here?__________________

8. Pupil Check( PERRLA ) Pupils, Equal, Round, React to

light, Accommodate

Sluggish ( ) No Change ( ) Brisk ( ) Normal ( )

Accommodation Yes ( ) No ( )

5/26/2013 Free Template from www.brainybetty.com 10


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Mr. Puso

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Mr. Puso, 52 y/o male

patient of Dr. Nerva,Left sided CHF with

pulm edema, CADand anginaAmerican Dream Review

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Landmarks

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Cardiac

9. Neck VeinsPatient at 45 degree angle ( )

Neck Veins Flat ( ) Distended ( )

10.Heart TonesApical Pulse with Stethoscope

Rate ?_____________

Rhythm ? ___________Clarity of Sounds ? _________ Abnormal ? ( )

Explain ! ____________________________

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Heart TonesHeart tones are checked by

listening to the apical pulse.

This pulse is auscultated with thebell of the stethoscope.

Check the apical pulse for rate,rhythm, and clarity of thesounds of the S1 and S2otherwise known as "lub and

dub".Any abnormalities should be

reported.


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Heart SoundsHeart sounds result from the vibrations from

closure of the heart valves and theacceleration and deceleration of blood flow.

S1 - the lub sound that represents closure

of the tricuspid and mitral valves. Heardbest at the apex.

S2 - the dub sound. This represents closureof the aortic and pulmonic valves. It is theonset of ventricular diastole and is heardbest at the aortic area.

S1 split - a slight difference in valve closuretiming. This is a normal variation heard bestat the right 4th intercostals space.


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Heart Sounds S2 split - this is a splitting of the dub, or the second sound.

Heard best during inspiration at the pulmonic area. Usually

disappears in the sitting position

S3 (ventricular gallop) - normal in healthy children and

young adults and is produced by vibrations of the ventriclesdue to rapid distention. This may be seen in left ventricular

failure. Heard best at the apex with the patient lying on the

left side. Heard with the bell of the stethoscope and sounds

like Kentucky. May indicate incompetence of the mitral and

tricuspid valves.

S1 S2 S3 Ken tuck ee Lub dub dub


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Heart Sounds

S4 (atrial gallop or presystolic gallop) - Heard best over the

apex with the pt in lying supine.

Indicative of increased resistance to filling and may be associated

with coronary artery disease, hypertension, aortic stenosis, or

the elderly.

This sound is heard best with the bell of the stethoscope over the

left lower sternal border. It sounds like Tennessee.

S4 S1 S2 Ten ne see Dub lub dub


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Heart SoundsClassifications

Diastolic Murmurs - occurbetween S2 and S1. Seenin mitral or tricuspid

stenosis, aortic or pulmonicinsufficiency.

Systolic murmurs - occurbetween S1 and S2. Seenin aortic or pulmonic

stenosis or mitral ortricuspid insufficiency. Theyare also called holosystolicor parasystolic murmurs.
http://www.med.ucla.edu/wilkes/inex.htm


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Heart SoundsHeart Murmurs - are caused by

increased flow through normalstructures.

Areas for AuscultationMitral murmurs are heard best with the

patient in the left lateral position.

Aortic murmurs are heard best withthe patient sitting and leaning forward

after complete exhalation.


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Cardiac

11. Bilateral Checks

( Radial Pulses ) - Rate, Strength, Regularity

Right_____________ Left______________

( Hand Strength ) - 2 fingers onlyRight Stronger ( ) Left Stronger ( ) Equal ( )

( Pedal Pulses DP/PT ) - Top of Foot

Right Foot __________ Left Foot ____________

( Capillary Refill ) - On fingers or toes 3 seconds or lessRight Fingers ( ) sec. Left Fingers ( ) sec.

Right Toes ( ) sec. Left Toes ( ) sec.

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Mr. Baga

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Mr. Baga, 70 y/o

chronic COPD of Dr.Dy, admitted for

dyspnea episode 2days ago


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Landmarks

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Pulmonary Assessment


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Pulmonary

12. Breath Sounds

Assess anterior and posterior and from side to side, left

to right lobe.

Have patient take deep breaths, do not movestethoscope to rapidly to avoid hyperventilating on

patients part.

Clear Bilaterally ( ) Left only ( ) Right only ( )

diminished, tight bilaterally ( )

Crackles or Rales, Fine or Coarse Crackles, Rhonchi

Good air flow ( ) Poor air flow ( )

ICSP __________

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Breath SoundsThe diaphragm of the stethoscope is

used for assessing breath sounds.

The right middle lobe is assessed bylistening on the patient's rightside.

Have the patient take deep breaths inand out of their mouth.

Nose breathing can create airturbulence that may alter thesounds.

Breath sounds should be clearbilaterally with good air flow.


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Breath SoundsNormal breath sounds

Bronchial sounds - Pitch: High. Intensity: Loud,predominantly on expiration. Normal findings: A soundlike air blown through a hollow tube

Bronchovesicular sounds - Pitch: Moderate.Intensity: Moderate. Normal findings: A blowing soundheard over airways on either side of sternum, at angleof Louis, and between scapulae

Vesicular sounds - Pitch: High on inspiration, low onexpiration. Intensity: Loud on inspiration, soft toabsent on expiration. Normal findings: Quiet, rustlingsounds, heard over periphery


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Breath SoundsAbnormal breath sounds - diminished, distant or tight

Bronchial sounds - Pitch: High. Intensity: Loud, predominantlyon expiration. Normal findings: A sound like air blown through ahollow tube

Bronchovesicular sounds - Pitch: Moderate. Intensity:

Moderate. Normal findings: A blowing sound heard over airwayson either side of sternum, at angle of Louis, and betweenscapulae

Vesicular sounds - Pitch: High on inspiration, low on expiration.Intensity: Loud on inspiration, soft to absent on expiration.

Normal findings: Quiet, rustling sounds, heard over periphery


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Breath SoundsADVENTITIOUS SOUNDS Crackles (Rales)

Where to auscultate: Over lung fields and airways; heard inlung bases first with pulmonary edemaTiming:More obvious during inspiration

Cause: Moisture, especially in small airways and alveoliDescription: Light crackling, bubbling; nonmusical

Rhonchi (Gurgles) and Coarse CracklesWhere to auscultate: Over larger airways

Timing: More pronounced during expirationCause: Airways narrowed by bronchospasm or secretionsDescription: Coarse rattling, usually louder and lower-pitched than crackles; described as sonorous, musical.Rhonchi typically clears with coughing.


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Breath Sounds Wheezes

Where to auscultate: Over lung fields and airwaysTiming: Inspiration or expirationCause: Airways narrowed by bronchospasmDescription: described as sonorous, musical, or sibilantCreaking, Whistling; high-pitched, musical squeaks

Pleural Friction RubWhere to auscultate: Front and side of the lung field

Timing: InspirationCause: Inflamed parietal and visceral pleural surfacesrubbing together.Description: Grating or squeaking


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Neck VeinsNeck veins should be checked by

having the patient sit at a 45

degree angle. In this position,

the jugular veins should be

flat.Distended neck veins at 45

degrees are an indicator of

over hydration or fluid

overload.


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Mrs. Tiyan

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Mrs. Tiyan, 45 y/o s/p

exploratory laparotomy ofDr. Espiritu, yesterday

afternoon


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Gastro-intestinal

13. Bowel Sounds Assess all 4 quadrants, do not touch stomach before

auscultation, as it may disrupt normal sounds. If

irregular,

1 minute assessment on each quadrant. Umbilicus ismid point.

( Stomach ) - Check for condition

Soft ( ) Hard ( ) Distended ( ) Other

RUQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( ) RLQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )

LUQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )

LLQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )



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Mr. Bahag-Hari

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Waiting for new admissionfrom PACU Mr.Bahag-Hari, s/p

suprapubic

prostatectomy of Dr. Sy.American Dream Review

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Genito-Urinary


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Genito-urinary

14. Ask the patientUrgency, Burning, Incontinence, pain

15.AssessCatheter, Drainage, Urine output

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Mrs. Asukar

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Mrs. Asukar, 65 y/o femalepatient of Dr. Tormes,

long-term Type Idiabetic, admitted for

episode of hypoglycemiayesterday


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Integumentary

16. Skin Skin Turgor - 1 to 3 second return, on Sternum

Return was ( ) sec. Abnormal ( ) sec.

Skin Color - Check on inside of Lip or Conjunctiva

Lip ( ) Conjunctiva ( )Pink ( ) Pale ( ) Jaundice ( ) Cyanotic ( )

Skin Temperature - Use back of hand to check

Hot ( ) Warm ( ) Cool ( )

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Braden Scale

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17. Skin Breakdown Check


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Peripheral EdemaEdema, or fluid in the tissues tends

to go to dependent areas of the

body. This may be the hands,

feet or sacrum.

For the bed rest patient, thedependent area is most often

the sacrum.

To check for edema push your

finger down on the feet, hands,and sacrum. Observe for

indentation or pitting.


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ASSESSMENT SCALE FOR


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ASSESSMENT SCALE FOR

PITTING EDEMA

1+ slight pitting, no visible distortion, disappears

rapidly

2+ somewhat deeper pit than 1+, no readily detectable

distortion, disappears in 10-15 sec.3+ pit noticeably deep, may last more than a minute;

the dependent extremity looks fuller and swollen.

4+ pit very deep, lasts 2-5 min; dependent extremity is

grossly distorted.


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Vascular

18.Peripheral Edema

Edema is found in dependent areas such as the feet,

hands, sacrum. Check with finger by pressing down.

Observe for pitting or indentation.Feet Yes ( ) No ( ) Pitting ( ) R ( ) L ( )

Hands Yes ( ) No ( ) Pitting ( ) R ( ) L ( )

Sacrum Yes ( ) No ( ) Pitting ( ) Indent

19. Distal Pulses Dorsalis Pedi and Post Tibial

Palpable or dopplerable

Arterial or venous

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Post Tibial

45

Dorsalis Pedis


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Vascular

20.Homan's SignAsk patient to dorsiflex both feet.

Pain in right calf Yes ( ) No ( )

Pain in both calves Yes ( ) No ( )

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Pain Assessent

21. Assessing For Pain (PQRST method)

P Provokes, palliative measure

Q Quality (describe)

R Region, radiate?S Severity, on a scale of 0 - 10

T timing, when did it start? How long does it last?

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Psychosocial

22. Psychosocial Aspects

Affect of illness on role such as work, family

Inappropriate independence, dependence?

Check for depression, suicidal ideation if

needed.

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Education Assessment

23.Response to learning

Learning barriers

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Closure

24. Closure

Let the patient know you are finished and

when you will be back.

Bedrails up ( )

Bed in low position ( )

Call light in reach ( )

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QandA


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ITS

SHOWTIME!


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