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There is 8 pages to fill in its assessment assigment one 2A 2B AND 3A AND 3B please look at it and let me know I am going to upload.They are due on different days Module 1 4/9 Module 2A/B 4/13 3A/B 4/16. I used my old assement book.
In this class you will be assessing an adult each week. You may not use a patient from your work (we do not want you to violate HIPAA), but need to choose someone from your private life—a family member, friend, coworker or fellow student, to be your “assessment buddy”. It must be an adult because medical history questions will be asked, and a child might be unable to answer them. You may select a different adult each week, and in fact might want to select someone with health problems in the area we are covering in a particular week—someone with COPD when we study the respiratory system, for instance.
1. Allstudentsareexpectedtopursuetheirscholasticcareerswithhonestyand integrity.Academic dishonestyincludes,butisnotlimitedto,cheatingonatestorothercoursework,plagiarism (offeringtheworkof anotherasone’sown),andunauthorizedcollaborationwithanotherperson. Studentsfoundguiltyof dishonestyintheirscholasticpursuitsaresubjecttopenaltieswhichmay includesuspensionorexpulsionfromtheUniversity. Pleaseseetheacademicdishonestysectionof thissyllabus. Every assignment is checked by anti-plagiarism software.
2. Studentsareresponsibleforcontactingfacultymembersforconsultationregardingaproblemwith, orquestionsabout,thecourse. Contact your coach first, and if the coaches cannot help you, they will forward your request to the faculty responsible for that function.
1. Weber, J. & Kelley, J. (2014). Health assessment in nursing (5thed.). Philadelphia: Lippincott.
Please note that the e-book does not have page numbers and some students have preferred a hard copy due to the nature of assignments in the course. On the other hand, one can search for specific words in the e-book, making it easy to find content. Either version will work, so select the format that is best for your learning style. Textbook rental or the purchase of used books are an economical way of getting access to the book.
10 General status, vital signs, pain and nutrition Subjective data Student Name________________ (No patient names or initials allowed). Submit using Word, with a .doc or .dox suffix; do not use .odt because the forms cannot be graded in that format—this goes for the assignments in all the upcoming weeks for this class. NOTE: YOU MAY NOT USE A PATIENT FROM YOUR WORKPLACE FOR THIS ASSESSMENT. WE DO NOT WANT YOU TO VIOLATE HIPAA! Questions Findings Current Status Allergies Present health concerns Current medications (prescribed and over-the-counter) Immunizations Past History Medical Surgical Hospitalizations Injuries Family History List family medical concerns for 3 generations Pain (Everyone has had pain at some time or other-if your patient is healthy and currently pain-free, you may need to use a past instance of pain.) Pain (using COLDSPA) Character: how does it feel—what sort of pain is it? Onset: Location: Duration: Severity (scale of 1 – 10): Pattern—what makes it better or worse: Associated factors—does it cause you to have other symptoms too? 18. How does pain impact the other areas of life? 2. What are your concerns about the pain’s effect on a. general activity? b. mood/emotions? c. concentration? d. physical ability? e. work? f. relations with other people? g. sleep? h. appetite? i. enjoyment of life? Lifestyle and Health Practices What types of recreation or physical exercise? Duration of exercise periods, how many times per week? Stress: Rate overall life stress on a scale of 1 – 10 (1 being least, 10 most). What are the greatest sources of stress? Methods of coping with stress? Use of tobacco, alcohol, recreational drugs Sleep—typical hours per night Objective data (General status and vital signs, pain and nutrition) Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, used with permission. Questions Findings Current Status Observe physical development (i.e., appears to be chronologic age). Observe skin (i.e., general overall color, color variation, and condition). Observe dress (occasion and weather appropriate). Observe hygiene (cleanliness, odor, grooming). Observe posture (i.e., erect and comfortable) and gait (i.e.,rhythmic and coordinated). Observe general body build (muscle mass and fat distribution). Observe consciousness level (alertness, orientation, appropriateness). Observe comfort level-does patient exhibit visible signs of pain? Observe behavior (body movements, affect, cooperativeness, purposefulness, and appropriateness). 10. Observe facial expression (culture-appropriate eye contact and facial expression). 11. Observe speech (pattern and style). Vital Signs Temperature (document route) Heart rate (pulse– rhythm, amplitude) (Document units—beats per minute) Respirations (rate, rhythm, and depth). (Document units—breaths per minute) Blood pressure Nutritional assessment: Subjective data Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current Status Type of diet (for instance, low carb, vegetarian, diabetic, etc.) Appetite changes Weight changes in last 6 months? Problems with indigestion, heartburn, bloating, gas? Constipation or diarrhea? Dental problems? Conditions/diseases affecting intake or absorption, i.e., irritable bowel disease, gluten sensitivities, etc.,? Frequency of dieting? Family History Chronic diseases? Weight issues? Lifestyle and Health Practices Average daily food intake—how many meals and snacks? Approximately how many 8-oz. glasses of fluid per day are consumed? Type of beverages consumed? Dine alone or with others? Frequency of eating out? Do long work hours affect diet? Sufficient income for food? Is a specific diet plan used? List a 24 hour recall of food intake. Objective data: Nutrition assessment Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current Status Measure height. Measure weight (1 kg = 2.205 lb). Determine body mass index (BMI = weight in kilograms/height in meters squared or use the NIH website: http//nhlbisupport.com/bmi/bmicalc.htm). Compare results to BMI in Table 13-3, on in the textbook. To which category does your assessment partner belong? BMI: Category: Measure waist circumference and compare findings to Table 13-5 in the textbook. Which category of risk captures this person’s situation? Waist circumference: Risk category: SBAR Read the instructions and rubric on the assignment form before completing this. As you have assessed your patient, which finding from the “General Status, Pain, Nutrition and Vital Signs” assessment would require attention from the clinician (if it is sufficiently serious to warrant medical attention) or from you as a nurse if it regards a health promotional/lifestyle problem? Select a problem you feel to be of importance and address it using the SBAR form. If you have a healthy assessment partner, it may be as simple as addressing that he/she gets insufficient exercise, is obese, or doesn’t eat a balanced diet—perhaps not as many fruits or veggies as recommended. Most people don’t drink enough water—you can often use that if nothing more serious is apparent. If your assessment partner has chronic health problems or pain, address one of those problems below. SBAR Situation (What is the most important problem you have identified? When did it start, and how severe is it?) Background (The evidence—Health history relating to this problem, what is being done, and what assessment findings are most important now.) Assessment (What do you think the problem is—which direction does it seem to be going?) Recommendation (What needs to happen next?) Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Assignment 2 A Hair, skin, nails (See below for head, neck and SBAR) Subjective data Name_______________ Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current Status 1. Skin problems as described by the assessment partner (ask them to describe all rashes, lesions, dry areas, any oiliness, drainage, bruising, swelling, or pigmentation issues) 2. Reported changes in lesion appearance 3. Reported changes in sensation (pain, pressure, itch, tingling) 4. Reported hair loss or changes 5. Reported nail changes Past History 1. Previous problems with skin, hair, or nails (treatment and surgery) Family History 1. Family history of skin problems or skin cancer Lifestyle and Health Practices 1. Exposure to sun or chemicals 2. Daily care of skin, hair, and nails (use of sunscreen, etc.) Head and neck Subjective data Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current Symptoms as reported by assessment partner 1. Reported nodules or lesions on head or neck. 2. Difficulty moving head or neck. 3. Facial or neck pain or frequent headaches. 4. Dizziness, lightheadedness, spinning sensation, or loss of consciousness. Past History 5. Previous head or neck problems/trauma/injury (surgery, medication, physical or radiation therapy) results. Family History 6. Family history of head and/or neck cancer. 7. Family history of migraine headaches. Lifestyle and Health Practices 8. Do you smoke or chew tobacco? Amount? Secondhand smoke? 9. Do you wear a helmet or hard hat? 10. Typical posture when relaxing, during sleep, and when working. Objective data: Hair, skin, nails Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings (In this class when describing objective data, you need to use professional terminology. Most students are weak in this area—review the correct terms in your textbook, such as macule, papule, pustule, etc. No using of “spot”, “bump”, etc.! 1. Inspect for generalized color variations (pallor, cyanosis, jaundice, erythema, vitiligo). 2. Inspect for skin reactive conditions, such as breakdown or calluses (if applicable, use staging criteria given in Chapter 13). 3. Describe primary, secondary, or vascular lesions. Describe lesions using clinical terminology—macule, papule, pustule, etc. 4. Palpate texture (rough, smooth) of skin, using palmar surface of three middle fingers. 5. Palpate temperature (cool, warm, hot) and moisture (dry, sweaty, oily) of skin, using dorsal side of hand. 6. Palpate thickness of skin with fingerpads. 7. Palpate mobility and turgor by pinching up skin over sternum. 8. Palpate for edema, pressing thumbs over feet or ankles. Scalp and Hair 9. Inspect color. 10. Inspect amount and distribution. 11. Inspect and palpate for thickness, texture, oiliness, lesions, and parasites. Nails 12. Inspect for grooming and cleanliness. 13. Inspect for color and markings. 14. Inspect shape. 15. Palpate texture and consistency. 16. Test for capillary refill. Objective data: Head, neck and lymph nodes Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Head and Face Inspect head for size, shape, and configuration. Palpate head for consistency while wearing gloves. 3. Inspect face for symmetry, features, movement, expression, and skin condition. 4. Palpate temporal artery for tenderness and elasticity. 5. Palpate temporomandibular joint for range of motion, swelling, tenderness, or crepitation by placing index finger over the front of each and asking client to open mouth. Neck 6. Inspect neck while it is in a slightly extended position (and using a light) for position, symmetry, and presence of lumps and masses. 7. Inspect movement of thyroid and cricoid cartilage and thyroid gland by having client swallow a small sip of water. 8. Inspect cervical vertebrae by having client flex neck. 9. Inspect neck range of motion by having client turn chin to right and left shoulder, touch each ear to the shoulder, touch chin to chest, and lift chin to ceiling. 10. Palpate trachea by placing your finger in the sternal notch, feeling to each side, and palpating the tracheal rings. 11. Palpate the thyroid gland. 12. Auscultate thyroid gland for bruits (use both bell and diaphragm of stethoscope). Lymph nodes: Palpate lymph nodes for size/shape, mobility, and tenderness (refer to display on characteristics of lymph nodes) 13..Preauricular nodes (front of ears) 14. Postauricular nodes (behind the ears) 15. Occipital nodes (posterior base of skull) 16. Tonsillar nodes (angle of the mandible, on the anterior edge of the sternocleidomastoid muscle) 17. Submandibular nodes (medial border of the mandible); do not confuse with the lobulated submandibular gland 18. Submental nodes (a few centimeters behind the tip of the mandible); use one hand 19. Superficial cervical nodes (superficial to the sternomastoid muscle) 20. Posterior cervical nodes (posterior to the sternocleidomastoid and anterior to the trapezius in the posterior triangle) 21. Deep cervical chain nodes (deep within and around the sternomastoid muscle) 22. Supraclavicular nodes (hook fingers over clavicles and feel deeply between the clavicles and the sternomastoid muscles) SBAR As you have assessed your patient, which finding would require attention from the Module 2 assessment? (Skin, Hair, Nails, Head, Neck, Eyes, Ears, Mouth, Nose, Throat, or Sinuses). Select a problem you feel to be of importance and address it using the SBAR form. If you have a healthy assessment partner, it may be as simple as addressing that he/she should utilize sunscreen or ceases using unsafe tanning methods. If your assessment partner has chronic health problems in one of the module areas, you may address one of those problems below. SBAR Situation (What is the most important problem you have identified? When did it start, and how severe is it?) Background (The evidence—Health history relating to this problem, what is being done, and what assessment findings are most important now.) Assessment (What do you think the problem is—which direction does it seem to be going?) Recommendation (What needs to happen next?)
12 Assignment 2 B Eyes and ears: (See below for mouth, nose, throat, sinuses) Note that for this assignment (as noted in the syllabus) you need a tuning fork and an otoscope. The instructor priced both of these and found an otoscope at a local drug store for less than $15.00, and a tuning fork from the internet for less than $10.00. These inexpensive models are adequate for this assignment—of course you may be able to borrow them from another nurse for the few moments required to do this assignment, or you may find that you would like to have your own, having learned to use them. Subjective data Name_____________________ Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current Symptoms: Eyes 1. Recent changes in vision? 2. Spots or floaters in front of eyes? 3. Blind spots, halos, or rings around lights? 4. Trouble seeing at night? 5. Double vision? 6. Eye pain? 7. Redness or swelling in eyes with regular daily activity? 8. Excessive watering or tearing or other discharge from eyes? Past History 9. Previous eye or vision problems (medication, surgery, laser treatment, corrective lenses)? Family History 10. Family history of eye problems or vision loss? Lifestyle and Health Practices 11. Exposure to chemicals, fumes, smoke, dust, flying sparks, etc.? 12. Use of safety glasses? 13. Use of sunglasses? 14. Medications (corticosteroids, lovastatin, pyridostigmine, quinidine, risperdal, and rifampin) may have ocular side effects? 15. Has vision loss affected ability to work or care for self or others? 16. Date of last eye examination? 17. Are corrective glasses or contacts worn regularly? Ears Current Symptoms 1. Recent changes in hearing (if yes, were all or just some sounds affected)? 2. Ear discharge (if yes, amount/odor)? 3. Ear pain (if yes, is there accompanying sore throat, sinus infection, or problem with teeth or gums)? 4. Ringing or crackling in ears? Past History 5. Previous ear or hearing problems such as infections, trauma, or earaches (medications, surgery, hearing aids)? Family History 6. Family history of ear problems or hearing loss? Lifestyle and Health Practices 7. Live or work around frequent or continuous loud noise? 8. Use of ear protection from noise or while in water? 9. Has hearing loss affected ability to work or care for self or others? Mouth, nose throat and sinuses: Subjective data Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current Symptoms 1. Mouth problems (tongue or mouth sores or lesions, gum or mouth redness, swelling, bleeding, or pain)? 2. Sinus problems (pain over sinuses, postnasal drip)? 3. Nose problems (nosebleeds, stuffy nose, cannot breath through one or both nostrils, change in ability to smell or taste)? Past History 1. Previous problems with mouth, throat, nose, or sinuses (surgeries or treatment; how much and how often)? 2. Use of nasal sprays? 3. History of tooth grinding? 4. Last dental exam? Fit of dentures? Family History 1. Family history of oral, nasal, or sinus cancer or chronic problems? Lifestyle and Health Practices 1. Daily practice of oral care, tooth care, or denture care? 2. Usual diet? (Type of diet is acceptable here—patient may say, “I try to eat low carb, high protein, and don’t succeed very well.” If they say they don’t really think about it and just eat what they like, use “General diet”. Don’t do 24 hour recall here—that will be done with the GI system. 3. History of smoking, use of, how much, and how often? 4. Use of alcohol (how much and how often)? Objective data: Eyes and ears Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current Symptoms: Eyes Perform Vision Tests The vision charts for these tests are available at no cost on the internet. 1. Distant visual acuity (with Snellen chart, normal acuity is 20/20 with or without corrective lenses). 2. Near visual acuity (with a handheld vision chart, normal acuity is 14/14 with or without corrective lenses). 3. Visual fields (use procedure discussed in textbook to test peripheral vision). Perform Extraocular Muscle Function Tests 4. Corneal light reflex (using a penlight to observe parallel alignment of light reflection on corneas). 5. Cover test (using an opaque card to cover an eye to observe for eye movement). 6. Positions test (observing for eye movement). External Eye Structures 7. Inspect eyelids and lashes (width and position of palpebral fissures, ability to close eyelids, direction of eyelids in comparison with eyeballs, color, swelling, lesions, or discharge). 8. Inspect positioning of eyeballs (alignment in sockets, protruding or sunken). 9. Inspect bulbar conjunctiva and sclera (clarity, color, and texture). 10.Inspect the palpebral conjunctive (eversion of upper eyelid is usually performed only with complaints of eye pain or sensation of something in eye). 11.Inspect the lacrimal apparatus over the lacrimal glands (lateral aspect of upper eyelid) and the puncta (medial aspect of lower eyelid). Observe for swelling, redness, or drainage. 12. Palpate the lacrimal apparatus, noting drainage from the puncta when palpating the nasolacrimal duct. 13. Inspect the cornea and lens by shining a light to determine transparency. 14.Inspect the iris and pupil for shape and color of the iris and size and shape of the pupil. 15.Test pupillary reaction to light (in a darkened room, have client focus on a distant object, shine a light obliquely into the pupil, and observe the pupil’s reaction to light—normally, pupils constrict). 16.Test accommodation of pupils by shifting gaze from far to near (normally, pupils constrict). Internal Eye Structure 17.Inspect the red reflex by using an ophthalmoscope or otoscope to shine the light beam toward the client’s pupil (normally, a red reflex is easily seen and should appear round with regular borders). (This is the “red-eye” seen in some home photographs.) Optional (all blue areas)–may do the following eye assessments if you can, though it is not always possible to do well without dilating the eyes–give it a try and see if you can identify any of the following. (Your score will not be affected by either your success or inability in this optional section in blue–it is a skill that takes quite a lot of practice! I recommend that you at least try so that if you take advanced practice classes you will have an idea how it feels.) 2. Inspect the optic disc by using the ophthalmoscope focused on the pupil and moving very close to the eye. Rotate the diopter setting until the retinal structures are in sharp focus (observe disc for shape, color, size, and physiologic cup). 3. Inspect the retinal vessels using the above technique (observe vessels for numbers of sets, color, diameter, arteriovenous ratio, and arteriovenous crossings). 4. Inspect retinal background for color and the presence of lesions. 5. Inspect the fovea and macula for lesions. Current Symptoms: Ears External Ear Structures 1. Inspect the auricle, tragus, and lobule for size and shape, position, lesions/discoloration, and discharge. 2. Palpate the auricle and mastoid process for tenderness. Otoscopic Examination 3. Inspect the external auditory canal with the otoscope for discharge, color and consistency of cerumen, color and consistency of canal walls, and nodules. 4. Inspect the tympanic membrane, using the otoscope, for color and shape, consistency, and landmarks. 5. Have the client perform the Valsalva maneuver, and observe the center of the tympanic membrane for a flutter. (Do not do this procedure on an older client, as it may interfere with equilibrium and cause dizziness.) Hearing and Equilibrium Tests An easy-to-perform test for higher-pitched sounds is to rub the tips of your thumb and index finger together, 2 – 3 inches from the patient’s ear—D. Furr 6. Perform the whisper test by having the client place a finger on the tragus of one ear. Whisper a two-syllable word (1–2 ft) behind the client. Repeat on the other ear. 7. Perform the Weber test by using a tuning fork placed on the center of the head or forehead and asking whether the client hears the sound better in one ear or the same in both ears. 8. Perform the Rinne test by using a tuning fork and placing the base on the client’s mastoid process. When the client no longer hears the sound, note the time interval, and move it in front of the external ear. When the client no longer hears a sound, note the time interval. 9. Perform the Romberg test to evaluate equilibrium. With feet together and arms at the side, close eyes for 20 seconds. Observe for swaying. (Refer to textbook, Chapters 16 and 26.) Mouth, nose throat and sinuses: Objective data Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current Status Mouth 1. Note any distinctive odors. 2. Inspect and palpate lips, buccal mucosa, gums, and tongue for color variations (pallor, redness, white patches, bluish hue), moisture, tissue consistency, or lesions (induration, roughness, vesicles, crusts, plaques, nodules, ulcers, cracking, patches, bleeding, Koplik spots, cancer sores), Stensen and Wharton ducts. 3. Inspect gums for hyperplasia, blue-black line. 4. Inspect teeth for number and shape, color (white, brown, yellow, chalky white areas), occlusion. 5. Inspect and palpate tongue for color, texture, and consistency (black, hairy, white patches, smooth, reddish, shiny without papillae), moisture, and size (enlarged or very small). Throat 1. Inspect the throat for color, consistency, torus palatinus, uvula (singular). 2. Inspect the tonsils for color and consistency; grading scale (1, 2, 3, or 4). Nose 1. Inspect and palpate the external nose for color, shape, consistency, tenderness, and patency of airflow. 2. Inspect the internal nose for color, swelling, exudate, bleeding, ulcers, perforated septum, or polyps. Sinuses 1. Palpate the sinuses for tenderness. 2. Percuss and transilluminate (if possible) the sinuses for air versus fluid or pus.
Thorax and lungs: Subjective & Objective data Name________________ Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current Symptoms 1. Difficulty breathing (at rest, with specific activities, while sleeping, other symptoms when having trouble breathing)? 2. Chest pain associated with a cold, fever, or deep breathing? 3. Cough, with or without sputum? Past History 1. Prior respiratory problems? 2. Previous thoracic surgery, biopsy, or trauma? 3. Allergies, symptoms/treatments? 4. Pulmonary studies/tests: chest x-ray, TB skin test, or influenza immunization? Family History 1. Family history of lung disease? Lifestyle and Health Practices 1. Use of tobacco products, cigarettes or e-cigarettes (number of years, number per day)? 2. Exposure to environmental conditions that affect breathing at work or at home, including secondhand smoke? 3. Difficulty performing usual daily activities? 4. Medications for breathing (prescribed or OTC), other breathing treatments? Thorax and lungs: Objective data Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current Symptoms Posterior Thorax Inspect for shape and configuration of the chest wall and position of scapulae. Inspect for use of accessory muscles. Inspect the client’s positioning noting posture and ability to support weight while breathing. Palpate for tenderness and sensation. Palpate for surface characteristics such as lesions or masses. Palpate for fremitus, using the ball or ulnar edge of one hand while the client says “ninety-nine.” Assess for symmetry and intensity of vibration. Palpate for chest expansion. Place hands on the posterior chest wall with your thumbs at the level of T9 or T10, and observe the movement of your thumbs as the client takes a deep breath. Percuss for tone, starting at the apices above the scapulae and across the tops of both shoulders. Percuss for diaphragmatic excursion, using the procedure in the textbook. AAuscultate for breath sounds (normal: bronchial, broncho-vesicular, and vesicular), noting location. AAuscultate for adventitious sounds (crackles, fine or coarse, pleural friction rub, wheeze, sibilant, or sonorous). (For this exercise, don’t use the term, “rhonchi”). AAuscultate for voice sounds over the chest wall: Bronchophony—ask the client to repeat the phrase “ninety-nine”; egophony—ask the client to repeat the letter “E”; whispered pectoriloquy—ask the client to whisper the phrase “one-two-three.” (In my experience, this particular technique has been of very limited value, but …this is a health assessment class, and is the place to learn of these rather interesting methods. You may encounter it at some point in your career.) Anterior Thorax Inspect for shape and configuration to determine the ratio of anteroposterior diameter to transverse diameter (normally 1:2). Inspect for position of sternum from anterior and lateral viewpoints. Inspect for slope of the ribs from anterior and lateral viewpoints. Inspect for quality and pattern of respiration, noting breathing characteristics, rate, rhythm, and depth. Inspect intercostal spaces while client breathes normally. Inspect for use of accessory muscles. Palpate for tenderness and sensation, using fingers. Palpate surface characteristics such as lesions or masses, using fingers of gloved hand. Palpate for fremitus while the client says “ninety-nine.” 10. Palpate for chest expansion by placing hands on anterolateral wall with the thumbs along the costal margins and pointing toward the xiphoid process. Observe the movement of the thumbs as the client takes a deep breath. Percuss for tone above the clavicles and then the intercostal spaces across and down, comparing sides. Auscultate for breath sounds, adventitious sounds, and voice sounds. Respiratory rate SBAR Read the instructions and rubric on the assignment form before completing this. As you have assessed your patient, which finding from Module 3 assessments would require attention from the clinician (if it is sufficiently serious to warrant medical attention) or from you as a nurse if it regards a health promotional/lifestyle problem? Select a problem you feel to be of importance and address it using the SBAR form. If you have a healthy assessment partner, it may be as simple as addressing. If your assessment partner has chronic health problems or pain, address one of those problems below. SBAR Situation (What is the most important problem you have identified? When did it start, and how severe is it?) Background (The evidence—Health history relating to this problem, what is being done, and what assessment findings are most important now.) Assessment (What do you think the problem is—which direction does it seem to be going?) Recommendation (What needs to happen next?)
Heart and Neck Vessels: Subjective data Name________________ Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current (or recent) Symptoms Chest pain (type, location, radiation, duration, frequency, intensity)? Palpitations? Dizziness? Ankle edema at any time of day? Past History Previous heart problems: heart defect, murmur, heart attack (MI)? Previous diagnosis of rheumatic fever, hypertension, elevated cholesterol, diabetes mellitus? Heart surgery or cardiac balloon intervention? Family History Hypertension? Myocardial infarction or heart disease? Elevated cholesterol? Diabetes mellitus? Lifestyle and Health Practices Cigarette smoking pattern? Life stress—type and amount? Usual exercise patterns? Sleep routine (use of extra pillows, up to urinate, feels rested)? Use of medications or treatments for heart disease? Self-monitoring of heart rate or blood pressure? How long ago was the last screening for blood pressure, cholesterol, ECG? Were there abnormal findings? Peripheral vascular system: Subjective data Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current Symptoms 1. Skin changes (color, temperature, or texture)? 2. Leg pain, heaviness, or aching? Does it awaken you at night? 3. Leg veins (rope-like, bulging, or contorted)? 4. Leg sores or open wounds (location, pain)? 5. Edema in legs or feet? 6. Swollen glands or nodules (pain)? Past History 1. Previous problems with circulation in arms or legs (blood clots, ulcers, coldness, hair loss, numbness, swelling, or poor healing)? 2. Heart or blood vessel surgeries or treatments Family History 1. Family history of varicose veins, diabetes, hypertension, coronary heart disease, or elevated cholesterol or triglyceride levels? Lifestyle and Health Practices 1. Women: use of hormonal contraceptives or therapy? 2. Peripheral vascular problems that interfere with ADLs? 3. Use of support hose? Heart and Neck Vessels: Objective data Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current Symptoms Neck Vessels 1. Auscultate carotid arteries for bruits. 2. Palpate each carotid artery for amplitude and contour of the pulse, elasticity of the vessel, and thrills. Heart (Precordium) 1. Inspect for visible pulsations (note if apical or other). 2. Palpate apical pulse for location, size, strength, and duration of pulsation. 3. Palpate for abnormal pulsations or vibrations at apex, left sternal border, and base. 4. Auscultate heart sounds for rate and rhythm (apical and radial pulses, beats/min, pulse rate deficit, S1 and S2). 5. Auscultate S1 and S2 heart sounds for sound location and strength pattern (louder/softer at locations and with respiration, splitting of S2). 6. Auscultate the following areas for extra heart sounds–clicks, rubs, perhaps murmurs: a. aortic b. pulmonic c. Erb’s point d. tricuspid e. mitral–note that this is level with the bottom of the sternum in the middle of the left side of the chest. Listen here for S3 or 4, esp. when pt is lying supine or on left side. Auscultate with the client in the left lateral position and with the client sitting up, leaning forward, and exhaling. Peripheral vascular system: Objective data Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions Findings Current Symptoms Assess Arms 1. Inspect bilaterally for size, presence of edema, and venous patterning. 2. Inspect bilaterally for skin color. 3. Inspect fingertips for clubbing. 4. Palpate fingers, hands, and arms for temperature, using dorsal surface of your fingers. 5. Determine capillary refill time. 6. Palpate radial, ulnar, and brachial pulses. 7. Palpate epitrochlear lymph nodes behind the elbow in the groove between the biceps and triceps muscles. 8. Perform Allen test by occluding the radial and ulnar arteries and observing for palm pallor. Then, release the ulnar artery and watch for color to return to hand. (Read about it thoroughly before beginning this exam.) Assess Legs 1. Inspect bilaterally for skin color (client in supine position). 2. Inspect bilaterally for distribution of hair. 3. Inspect for lesions or ulcers (note whether margins are smooth and even, location such as at pressure points, size, depth, drainage, odor). 4. Inspect for edema, unilateral or bilateral (if calves are asymmetric, measure calf circumference). 5. If client has edema, determine whether it is pitting or nonpitting. If client has pitting edema, rate on a 1+ to 4+ scale. 6. Palpate skin temperature (cool, warm, hot). Use dorsal surface of hands. 7. Palpate the superficial inguinal lymph nodes while keeping the genitals draped. If detected, note size, mobility, or tenderness. 8. Palpate and auscultate femoral pulses over artery. Listen for bruits. 9. Palpate popliteal, dorsalis pedis, and posterior tibial pulses. 10. Inspect for varicosities and thrombophlebitis by asking client to stand. 11.Perform the manual compression test by having client stand. Firmly compress the lower portion of the varicose vein with one hand. Place other hand 6 to 8 inches higher. Feel for pulsation in the upper hand.
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