Bedside assessment ch. 30

Cardiovascular System

Auscultate Rhythm at apex Apical Pulse and Radial Assess Heart Sounds Capillary Refills Palpate Tibial Pulse Palpate Dorsalis Pedis Pulse

Which priority action should the nurse take when performing an initial assessment of pain status of a patient who is receiving pain control via patient-controlled analgesia (PCA)? A. Confirm that the correct intravenous (IV) fluid is hanging. B. Determine when the patient last used the PCA button by looking at patient history on the PCA. C. Ask the patient to rate his or her pain on a numeric scale of 1 to 10. D. Position the patient for comfort.

C. Ask the patient to rate his or her pain on a numeric scale of 1 to 10. The priority action would be to assess the patient's pain status at the present time so as to provide a baseline for future assessment and to determine if the present method is providing relief. Confirming that the correct IV fluid is hanging is required; it is not the priority action at this time. The nurse will have to review the history profile on the PCA, but it is not the priority action at this time. Although the nurse may have to position the patient for comfort, it is not the priority assessment at this time.

Respiratory System

Check masks Flo of O2 Auscultate breath sounds Cough and Deep Breath Possible Spirometer

Background

Don't state patients full history but do state exactly what happening in that moment?

Neurologic System

Eyes opening properly Motor responses PERRLA Any Ptosis Communication Ability to Swallow

Activity

Know patients activity orders If ambulatory assist

Health History

On the way to the room verify markers or flags placed at the doorway regarding conditions.

EHRs Electronic Health Records

They replace the paper medical record, placing all relevant patient relevant info in an easily accessible electronic system. Solely focuses on patient information. Great for patients with chronic illness. Aids in patient safety and quality of care.

Measurement

Vital Signs Pulse OX Pain Levels

Situation

What is happening right now? Why are you calling?

General Appearance

-Facial expression: Is it appropriate to the situation -Body Positioning -LOC -Skin Color -Nutritional Status: Weight appears normal skin hydrated -Speech -Hearing -Personal Hygiene

Which of the following patients should the nurse assess first? A. A 48-year-old patient with shortness of breath and pulse oximeter reading of 88% B. A 52-year-old patient with a white blood cell count of 22,000 cells/mm3 C. A 59-year-old patient with chest pain that increases with deep inspiration D. An 89-year-old patient with a urinary tract infection who is confused

A. A 48-year-old patient with shortness of breath and pulse oximeter reading of 88% The nurse should use the ABCs to determine which order to assess the patients. The nurse should assess the 48-year-old patient with respiratory problems first (shortness of breath and pulse oximeter reading of 88%). The 52-year-old patient with an elevated white blood cell count should be assessed last. The 59-year-old patient with chest pain should be assessed second. The 89-year-old patient who is confused should be assessed third because of the confusion and risk for a fall or injury.

What is an advantage for using SBAR during staff communication? A. Improves verbal communication and reduces medical errors B. Provides a complete patient health history C. Focuses on a comprehensive physical examination D. Avoids making recommendations

A. Improves verbal communication and reduces medical errors SBAR improves verbal communication and reduces medical errors. SBAR communication is concise and focused; SBAR does not include a complete patient health history. SBAR communication is concise and focused; SBAR communication does not include a comprehensive physical examination. SBAR communication includes "R," which is making recommendations.

A nurse is evaluating the neurologic system of a patient. Which assessment would be included in the neurologic examination? A. Observe the patient for ptosis. B. Check the patient for borborygmi. C. Ask the patient if he or she has experienced nausea or vomiting. D. Check capillary refill.

A. Observe the patient for ptosis. Observation if the patient has ptosis (drooping of the eyelid) is part of a neurologic examination. Checking the patient for borborygmi (hyperactive bowel sounds that are associated with the stomach making audible rumbling sounds) would be included in the gastrointestinal examination. Asking the patient if he or she has experienced nausea or vomiting would be included in the gastrointestinal examination. Checking capillary refill would be included in the cardiovascular examination.

The nurse is calling the health care provider about a patient's changing condition. Which of the following would be included in the SBAR communication? A. Situation, background, assessment, and recommendation B. Subjective information, background, assessment, and revisions needed C. Situation, background, all vitals, and review of orders D. Summary, better plan, accurate diagnosis, and rights

A. Situation, background, assessment, and recommendation SBAR communication stands for situation, background, assessment, and recommendation.

Abdomen

Assess contour of stomach Listen to bowel sounds in all four quadrants Assure stool is passing Knowing diet orders

The nurse administers an intravenous dose of pain medication. The nurse should reassess the patient in: A. 5 minutes. B. 15 minutes. C. 30 minutes. D. 60 minutes.

B. 15 minutes. After an intravenous dose of pain medication, the nurse should reassess the patient in 15 minutes. If the pain medication was oral, the nurse should reassess the patient in 60 minutes.

A patient has a urinary catheter. Which assessment should be done each time vital signs are taken on the patient? A. Emptying the drainage bag and noting the output B. Observing the color of the output C. Repositioning the catheter to ensure there is no occlusion or blockage D. Adding additional water into the system to ensure that the balloon is inflated

B. Observing the color of the output The nurse should observe and note the color of the output at each vital sign check. Emptying the drainage bag is required at change of shift and when the bag is too full according to protocol. Repositioning the catheter should be done if there is evidence of occlusion or decreased urinary flow. There is no need to add additional water into the system each time the vital signs are taken because this could lead to increased pressure in the system.

The nursing assistant takes the vital signs for the 12 patients on the unit. Who is responsible for interpreting the results? A. The nursing assistant should review the results for abnormalities. B. The registered nurse assigned to the patient(s) should interpret the vital signs. C. The charge nurse is responsible for reviewing the vital signs on all 12 patients. D. The unit manager must ensure that the nursing assistant reports any abnormal results.

B. The registered nurse assigned to the patient(s) should interpret the vital signs. The registered nurse assigned to the patient(s) is responsible for interpreting the results. The registered nurse is also responsible for delegating vital signs and for supervising the nursing assistant.

Which finding would require immediate action by the nurse if found during the physical assessment? A. Systolic blood pressure of 152 mm Hg B. Heart rate of 60 beats per minute C. Oxygen saturation of 88% D. Respirations of 20

C. Oxygen saturation of 88% Oxygen saturation of 88% represents a critical result and requires immediate action. Systolic blood pressure of 152 mm Hg does not require immediate action, but the nurse should continue to monitor. Heart rate of 60 beats per minute is still within normal limits. Respirations of 20 are within normal range.

Skin

Color Temperature Pinch up a fold of skin under clavicle on forearm for turgor Check skin integrity Date IV site

Know your stuff before entering

Constantly asking the same question to the client by each person that comes into contact with the patient can be dreadful.

A nurse is reviewing a patient's vital signs that have been taken by a nursing assistant and noted in the patient's medical record. The blood pressure measurement noted is 60/40. What should the nurse do based on reviewing this information in the patient's chart? A. Review the information and as long as the nursing assistant has not reported any concern, proceed with other patient care. B. Have the nursing assistant retake the blood pressure because the reading is low. C. Make a note to retake the blood pressure in an hour to see if there is a change. D. Go directly to the patient and retake the blood pressure.

D. Go directly to the patient and retake the blood pressure. Retaking the blood pressure is appropriate and timely. The nurse should make a thorough assessment. It is the nurse's responsibility to interpret vital signs. Although a nursing assistant can help with technical skills, the nurse must evaluate findings. Interpretation of abnormal vital signs requires the nurse to take action. At this point, the prudent nurse should assess the patient directly. Because the reported value is extremely low, the nurse should take immediate action and not wait.

What is the purpose of the SBAR?

SBAR was first developed in the US military to standardize communication errors. It handles important in the moment information. Message will be focused and precise to the immediate problem.

SBAR

Situation Background Assessment Recommendation

SOAP

Subjective Objective Assessment Plan

Assessment

What do you think is happening in regard to the current problem post assessment.

Recommendation

What do you want the physician to do to improve the patients situation.