NURS 1660 Lecture Notes - Lecture 2: Cardiovascular Disease, Femoral Artery, Stethoscope
26 Jun 2018
School
Department
Course
Professor
11-63-166
Health Assessment I
Unit One
CHAPTER FIVE: Documentation and Interprofessional Communication (Pgs. 91 - 124)
Key Terms:
● Audit: A review of records of a health care facility by an agency to determine whether
that facility is providing and documenting certain standards of care.
● Batch Charting: Waiting until the end of shift or until all patients have been assessed to
document findings from all of them. → contributes to errors (ie. forgetting information).
● Charting by Expectation: Use of predetermined standards and norms to record only
significant assessment data.
● Confidentiality: Keeping information private.
● Flow Sheet: A standardized form that assembles the collected information in a way that
permits easy comparison among assessment data to detect trends or sudden change in
status.
● Handoff: Transfer of care for the patient from one healthcare provider to another.
● Point-of-Care Documentation: When nurses document information as they gather it;
usually using a portable computer.
● Clinical Pathway: a tool that identifies a standard care plan for a specific patient
population (ie. those undergoing hip replacements).
● Reporting: Communication that occurs at handoffs, during patient rounds, during patient
and family care conferences, when paging a health care professional to report a change
in status or provide requested information.
Common Abbreviations
CBE: Charting by Expectation.
CPOE: Computerized Provider Order Entry.
DAR: Date, Action, Response.
PIE: Problem, Intervention, Evaluation.
POC: Plan of Care.
SBAR: Situation, Background, Assessment, Recommendation. → for communications between
and among clinicians. It encopaaces the nurses’ suggestions for the next nterventions.
Commonly used when contacting a physician about a patient’s condition.
SOAP: Subjective, Objective, Analysis, Plan.
Four Documentation Formats:
Narrative Notes - record assessments and nursing activities in a unstructured paragraph.
SOAP Notes - focuses on a single condition.
PIE Notes - Its goal is to incorporate the Plan of Care into the progress note.
Focus Note - focuses on identified or new issues.
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Week Two (Sept. 18-22, 2017)
Katie Bakker
CHAPTER SIX: General Survey and Vital Signs Assessment
Objectives for this chapter:
❏List the four main areas involved when assessing the general survey
❏Describe and demonstrate (lab) how to:
❏Take temperature
❏Take blood pressure
❏Take pulse
❏Respiration
❏Explain hypertension
❏Identify the factors that affect blood pressure and other vital signs
❏Identify common abnormalities in general survey and vital signs
❏Describe variations in measurement and vital signs across the lifespan
General Survey: General Inspection
- The general survey begins with the first moment of encounter and continues throughout
the health history, during the physical exam and with every interaction. It is the first
component of the assessment, when the nurse makes mental notes of overall behaviour,
physical appearance, and mobility.
- When a nurse introduce themselves, they shake hands with the patient as appropriate to
the situation; it portrays caring but also allows assessment of the patient (hand strength).
- As the nurse proceeds through the assessment, they note the four components of
general survey:
→ Physical Appearance.
→ Body Structure.
→ Mobility (posture, gait (manner of walking), motor activity).
→ Behaviour (insight, judgement, cognitive functions, thought processes).
- Data collection begins as soon as the nurse enters the area of the patient or just hears
the patient talking.
Physical Appearance
Overall Appearance:
- Any noted deformities; do they look well? Do they appear stated age? Face,
movements and and body are symmetrical.
Hygiene Grooming and Dress:
- Observe clothing, skin, nails and hair. I their clothing appropriate for gender,
culture, age, weather, context?
- Is clothing clean and neat or disheveled? Does it fit?
- Are any breath or body odours noted?
- Is the patient’s skin clean and dry? Are nails and hair groomed, neat, and clean?
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Week Two (Sept. 18-22, 2017)
Katie Bakker
Skin Colour and Lesions:
- Observe for even skin tones and symmetry. Note any areas redness, pallor,
cyanosis, or jaundice. Observe any lesions or variations in pigmentation. Note
amount, texture, quality, and distribution of hair.
Body Structure and Development:
- Is the patient’s physical and sexual development consistent with expected
findings for stated age?
- Is the patient obese or lean or emaciated?
- Is the height appropriate for age and genetic background?
- What is the patient’s build? Is the patient barrel chested?
- Note the fingertips; are there any joint abnormalities?
Behaviour
Note the patient's behavior; are they cooperative or uncooperative? Is affect animated or
flat? Do they appear anxious?
Facial Expressions:
- Assess face for symmetry. Note expressions while the patient is at rest
and during speech and whether it seems appropriate. Does the patient
maintain eye contact appropriate to culture?
Level of Consciousness:
- Can the patient state his or her name, the date, month, time of day?
- Note any confusion, lethargy, or inattentiveness.
- To tell if the patient is oriented, ask them the following questions.
- Tell me your full name.
- Where are you now?
- What is today’s date?
- What time of day is it?
- Why are you here today? → oriented to situation question.
Speech:
- Listen to the speech pattern; are they speaking rapidly or very slowly? Is
speech clear and articulate?
- Are they fluent in the language or do they need an interpreter?
Mobility
Posture:
- Note how the patient sits and stands. Are they sitting upright?
- When standing, are they straight and aligned?
Range of Motion:
- Can the patient move all the limbs equally? Are there limitations?
Gait:
- If the patient is ambulatory, observe his or her movement around the
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