Assessment/Documentation LPN Research Study With Verified Answers.

Explain how and why the nurse must establish rapport w the clients before starting the assessment - correct answer Introduce self- name, position, purpose, ask permission, allow ?s before beginning, give time. Communicate trust- confidentially, understanding. Professional Manner- non-judgmental, call by Mr. or Ms. Interview should be relaxed, unhurried. Convey concern. May be a patient first assessment & object is establishing a affective Nurse/patient relationship. How to start the initial assessment process- - correct answer introduce self, develop rapport, nursing history, physical assessment, and etc... health HX per client/family, why seeking care now and psychosocial. Identify the different assessments- medical, initial, admission, focus assessment and who does each - correct answer Medical assessment/physical exam by physician- detailed medical exam w/ lab valve and tests results. LPN does assistive functions. detailed medical exam w/ lab valve and tests results. initial assessment = Initial assessment-(on-going) beginning of each shift-general assessment-w/attention to admission medical diagnosis admission assessment = Initial comprehensive admission assessment- comprehensive assessment performed on pt admission usually by RN focus assessment = Focused assessment -concentrates on particular part of the body by LPN. involves specific set of observations r/t condition or disorder (neurological-head trauma, post-op surgery-hemorrhage, neurovascular -ck cir., Finger stick blood sugar(FSBS) **Explain differences neurological and neurovascular assessment and how/when each is performed: - correct answer a focused assessment. neurological-head trauma, post-op surgery-hemorrhage,. neurovascular -ck cir., Finger stick blood sugar(FSBS). Neurological asses: includes LOC, verbal clues (can they comply correctly), Motor function (move extremities, smile, lift brows), pupillary response (pen light), proprioception (sensation of body movements & posture awareness), deep tendon reflexes, cranial nerve assessment (done by RN) Explain indications of positive bruits and Homan's sign and (how to perform each) - correct answer Bruits: Auscultation of the carotid artery can be per- formed by listening with the bell of the stethoscope. Normally, no bruits are audible. Bruits are abnormal "swishing" sounds heard over organs, glands, and arteries. A + bruit may indicate vessel blockage. Homan's sign: + Homas's or no palpable pulse may indicate-thrombosis-blood clot. Examine the patient's legs by stretching and straight- ening each leg, then using dorsiflexion on the foot. Pain in the calf is a positive Homans' sign, possible thrombophlebitis. Notify the physician promptly. neurovascular: circulation check: circulation, motion, sensation. Paresthesia, pallor, pain Explain how to determine client's orientation X 4 - correct answer the nurse determines the patient's level of consciousness (LOC) and level of orientation. Is the patient oriented to person, place, time, and situation/purpose? Determine the difference in assessing for objective and subjective data (with examples) - correct answer Objective data- observable, felt, measurable signs. Eg: Erythema area, edema. Abdomen- distended w/active bowel sounds in 4 quadrants. Infiltration of IV. Rash of skin. Edema goes to gravity-see rating sheet. Wound drainage- color & amt. Exudate-slow drainage. Foley catheter patent w/ clear straw urine Subjective data-Symptoms as perceived by client. Pain, anxiety, nausea, aching, no BM X 3 days. Fatigue & tiredness. Dizzy, Burning, tingling. Nurse needs to inquire onset, course, duration & character Explain the 4 different techniques utilized in physical assessment with rationales for each - correct answer Interviews-health Hx per client/family, why seeking care now and psychosocial Hx Inspection = Purposeful observation of physical & behaviors Auscultation = Listening w/ steth to body sounds (CV, Lungs, GI) Palpation = Feeling w/ fingertips density and placement of organs Percussion = Finger tips to tap over organs (vibrations) low pitch & high pitch over gas Identify how to assess client w dark brown skin tones (Palm and soles of feet, MM, lips, tongue, conjunctiva) - correct answer Assessment is easier in areas where the epidermis is thin, such as the lips and mucous membranes. The darker a person's skin, the more difficult it is to assess for changes in color, Color cannot be used as an indicator of systemic conditions in darker skinned individuals (e.g., flushed skin with fever). Establish a baseline in natural lighting if possible or with (at least) a 60-watt light bulb. Assess baseline skin color in areas with the least pigmentation, such as palms of the hands, soles of the feet, underside of forearms, abdomen, and buttocks. All skin colors have an underlying red tone. Pallor in black-skinned individuals is seen as ashen or gray. Pallor in brown-skinned individuals appears as yellowish. Assess pallor in mucous membranes, lips, nailbeds, and conjunctivae (i.e., the inner surface) of the lower eyelids. To assess rashes and skin inflammation in dark-skinned individuals, rely on palpation for warmth and induration (i.e., an abnormally hard spot) rather than observation. Determine the significance of signs/symptoms (s/s) of dehydration, carotid bruit, JVD, PERRLA( and how to perform it), abnormal mucous membranes (thick white plauge in mouth- abnormal signs) - correct answer dehydration =decreased skin turgor and is manifested by lax skin that, when grasped and raised between two fingers, slowly returns to its previous position (skin "tenting"). MM look dry. (skin = warm,dry,pale, decreased skin turgor) carotid bruit = Palpate the carotid arteries gently and one at a time. The normal carotid pulse is regular and palpable without a thrill (a vibrating sensation the nurse perceives during palpation along the artery). Auscultation of the carotid artery can be per-formed by listening with the bell of the stethoscope. Normally, no bruits are audible. Bruits are abnormal "swishing" sounds heard over organs, glands, and arteries. A bruit results from an abnormality in an artery that results from a narrow or partially occluded artery, such as occurs in atherosclerosis