NURS 161 Symptom analysis/ Assessment guides
Shoreline Community College -Review Symptom Analysis tools in the N161 section of the syllabus. -Assessment Guide: See the Entry Level Nursing Physical Assessment
Terms in this set (28)
The following eight characteristics need to be addressed for each complaint the patient has. Following this format will enhance both written and oral communication of data. It will help keep you on task and will help you to organize the data in a succinct, chronological format. In addition, it will promote critical thinking as you sift through the data and generate ideas about what they mean.
2. Character or Quality
3. Quantity or Severity
6. Aggravating or Relieving Factors
7. Associated Factors
8. Emotional/Cognitive Responses
Ask the patient to point to the location. If the symptom is pain identify if it is localized or if it radiates.
Character or Quality
This calls for specific descriptive terms such as burning, sharp, dull, aching, gnawing. Use similes like - did your urine look like tea? Did the vomitus look like coffee grounds?
Quantity or Severity
Attempt to quantify the symptom, for example "profuse menstrual flow soaking 5 pads/hour". Ask the patient to grade the symptom on a scale, for example 2/5, where 0=none and 5=the worst pain, nausea, swelling, etc. they have ever felt, or had. Document like this: pt. c/o 6/10 RLQ pain since breakfast.
When did the symptom first appear? Try to get the specific day/month/time and document that. Do not chart "leg weakness started 3 weeks ago" which forces all future readers of your charting to count back from the date of data entry. The report must include questions such as duration, if it was constant or intermittent, and any cycles of remission and exacerbation.
Where was the person when the symptom(s) first occurred and what was the pt. doing when it started? Is there something that seems to trigger the symptom? For example, "Does the shortness of breath occur when you are resting or when you are active?"
Aggravating or Relieving Factors
What makes the symptom worse or better? Does activity, rest, medications, weather, time of day, food, or the environment worsen the symptom? What makes it better; ice, heat, rest, exercise, medications, food, change in position? What have you tried, what seems to help?
Are there other symptoms that occur along with this symptom? For example, depression, nausea, pain, vomiting, diarrhea, chest pain, dizziness, fever, or chills?
Make a nursing judgment on whether or not you will ask this question. It will be based on the patient, and the situation, and will not be a question that is always appropriate to ask. However, if you decide to pursue this you might ask, "What do you think is going on?" This can give you information and insight into the patient's human response that the other questions may not provide. Finally, you might also ask the patient, "is there anything else you would like to add?"
Entry Level Nursing Physical Assessment Guide
During the course of the nursing physical assessment it is expected that you will:
1. Introduce yourself and explain what you are about to do
2. Explain procedures, as appropriate, and give clear instructions
3. Respect the patient's privacy; drape for dignity and warmth
4. Attend to the patient's physical comfort and meet immediate needs first
5. Plan assessment so procedures are smooth, and minimize frequent position changes.
12 Things to do for an Entry Level Nursing Physical Assessment
1. Obtain General Data
2. ASSESSING the HEAD and FACE
3. ASSESSING the EYES and CRANIAL NERVES (CN)
4. ASSESSING the MOUTH, THROAT
5. ASSESSING the EARS
6. ASSESSING the NOSE
7. ASSESSING the NECK
8. ASSESSING the UPPER EXTREMITIES
9. ASSESSING the POSTERIOR THORAX
10. ASSESSING the ANTERIOR THORAX
11. ASSESSING the ABDOMEN
12. ASSESSING the LOWER EXTREMITIES and FEET
Obtain General Data
1. Complete a brief mental status assessment: ABCT (appearance, behavior, cognition, thought processes)
2. Observe general appearance/signs of distress
3. Interview client for any presenting symptoms or concerns
4. Complete vital signs
ASSESSING the HEAD and FACE
1. Inspect hair, palpate skull and scalp
2. Assess facial symmetry
ASSESSING the EYES and CRANIAL NERVES (CN)
1. Inspect orbits, lids, lashes, conjunctiva, sclera, iris
2. Assess visual acuity/near and far (CN II) using Jaeger and Snellen charts
3. Test EOM's (CN III, IV, VI)
4. Assess PERRLA/direct & consensual response
5. Assess peripheral vision (confrontation)
PUPILS EQUAL, ROUND, REACTIVE TO LIGHT AND ACCOMMODATION
ASSESSING the MOUTH, THROAT
1. Assess Cranial Nerve VII - facial, CN IX - glossopharyngeal
2. Inspect lips, mucosa, gums, and teeth
3. Assess Cranial Nerve ___ Maxilla
4. Inspect tongue & tongue protrusion (CN XII)
5. Inspect hard & soft palates, pharynx, tonsils
6. Inspect movement of uvula with phonation (CN IX, X & XII)
ASSESSING the EARS
1. Inspect external ear/palpate auricle and tragus
2. Assess hearing using Rinne, Weber and Whisper tests
hearing test using a tuning fork; checks for differences in bone conduction and air conduction
Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard.
Auditory Nerve: Whisper in patients ear and ask them to repeat what you said
ASSESSING the NOSE
1. Ask about smell (CN I - olfactory)
2. Check nostril patency
3. Inspect nasal passages
ASSESSING the NECK
1. Inspect for symmetry, masses and scars. Inspect for trachea midline.
2. Test Cranial Nerve XI by pressing head and neck
3. Palpate carotid pulses and auscultate for bruits
ASSESSING the UPPER EXTREMITIES
1. Palpate, inspect skin for warmth, lesions, nails, nail beds
2. Assess grip bilaterally, skin temperature/ moisture/ edema
3. Assess capillary refill
4. Assess radial pulses, bilaterally for rhythm and strength
5. Assess ROM shoulders bilaterally
6. Assess bicep and triceps DTR's (at the end of the exam)
ASSESSING the POSTERIOR THORAX
1. Palpate for tenderness and confirm symmetric chest expansion
2. Palpate spine for midline placement
3. Auscultate lung sounds in systematic manner
ASSESSING the ANTERIOR THORAX
1. Auscultate lung sounds in a systematic manner to lateral lobes
2. Auscultate S1 and S2, listen for extra sounds and murmurs
ASSESSING the ABDOMEN
1. Inspect skin. Assess for contour, symmetry, aortic pulse
2. Auscultate bowel tones in a systematic way, beginning in lower quadrant
3. Percuss all four quadrants in systematic way
4. Palpate lightly for tenderness; watch patient's face
ASSESSING the LOWER EXTREMITIES and FEET
1. Assess feet: skin and nails, edema, color, hair, capillary refill, ROM, temperature, DP/PT pulses, Homan's sign
2. Assess for ROM of hips, knees and feet
3. Assess mobility, gait and balance
4. Assess patellar and Achilles DTR's at the end of the exam
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