Continue your Nursing Health Assessment. Please include rational for assessment techniques. (why do you assess a certain way and what findings are you looking for).
Please answer questions as if you are a nurse providing assessment to the a patient.
Gastrointestinal Assessment
Inspect for contour, symmetry, peristalsis and condition of skin.
Auscultate all quadrants.
Palpates lightly for tenderness or masses.
Genitourinary Assessment
Inspect and obtain history of urine color and clarity, voiding patterns, need for assistance.
Describe expected findings and how do they compare with the person you assessed.
Palpate bladder for distention. What is expected. Why would someone need a Foley catheter?
Complete Examination-how is this done and rationale.
Cover and position patient for comfort and safety, assess pain level
Perform environmental check (side rails up, bed low, call light) and safety
Perform hand and stethoscope hygiene
Write assessment note. List at least 1 Nursing Diagnosis
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Date |
Progress Note |
Date: 26.11.2018
Nursing Assessment: observe the contour, symmetry, peristalsis of the abomen.Oberve for skin changes, smoothness, colour
Rationale: to identify for any external pathology.Eg. Red colour indicates infection, black colour indicates necrosis, distended veins indicates portal hypertension.
Skin colour with striae white colour in pregnancy, pink colour in cushing's syndrome. Localised hyper pigmentation is seen in Cullen's sign, Grey Turner's sign.
Movement of breathing is restricted in peritonitis, enlargement ascitis and cirrhosis.
Nursing assessment: Auscultate the abdomen.
Rationale: bowel sounds may be absent in some diseases which affects peristalsis, intra organal rub, bruit sound produced by atherosclerosis.
Nursing Assessment: palpate the abdomen light and deep.
Rationale: tenderness indicates any infection, rebound tenderness as in appendicitis, rigidity, epigastric tenderness in peptic ulcer or pancreatitis, right lowr quadrant pain in apendicits or perforated carcinoma, flank tenderness in renal pathology, generalized pain in peritonitis.
Genito urinary assessment
Nursing assessment: Observe the colour and clarity of urine.
Rationale: pale colour indicates diuresis, dark colour indicates dehydration, black colour indicates some drug intakes, blue colour indicates hypercalcemia, dark brown due to antibiotics or kidney damage, cloudy urine due to albinuria or UT infection.
Nursing Assessment: Enquire about frequency of urination.
Rationale: increased frequency is ffound in diabetes, diuresis and decreased frequency may indicate any block or kidney dysfunction.
Nursing Assessment: Palpate the bladder for
distention.
Rationale: distended bladder indicates absence of voiding. Foley's catheter is indicated for distended bladder when cleint cannot void.
Nursing Diagnosis: Potential for infection related to prolonged catheterization as evidenced by redness in catheterised site.
Nusing Implementation:
1. Assess the extent of infection.
2. Provide catheter care twice a day with betadine solution to prevent further infection.
3. Change the Foley catheter once in three days.
4. Follow strict aseptic techniques during catheterisation.
5. Maintain fluid volume balance since decreased fluid intake may increase the chance of infection.
6. Administer antibiotics if required as per Physician's instruction.
Continue your Nursing Health Assessment. Please include rational for assessment techniques. (why do you assess a certain...
Continue your Nursing Health Assessment. Please include rational for assessment techniques. (why do you assess a certain way and what findings are you looking for). Please answer questions as if you are a nurse providing assessment to the a patient. Cardiovascular Assessment: Inspect and Palpate for Pulsations on Chest and at PMI (state what and where the PMI is located), describe. Auscultate heart sounds in correct ausculatory areas. First, use diaphragm of stethoscope. The, use the bell of the stethoscope....
Continue your Nursing Health Assessment. Please include rational for assessment techniques. (why do you assess a certain way and what findings are you looking for). Cardiovascular Assessment: Inspect and Palpate for Pulsations on Chest and at PMI (state what and where the PMI is located), describe. Auscultate heart sounds in correct ausculatory areas. First, use diaphragm of stethoscope. The, use the bell of the stethoscope. What do you hear and why? Correctly name ausculatory sites and state where S1 and...
Head to toe assessment HOW TO WRITE: YOU ARE TO CREATE A PICTURE OF YOUR PATIENT General appearance: Affect/behaviour/anxiety Level of hygiene Body position Patient mobility Speech pattern and articulation This is not a specific step. Evaluating the skin, hair, and nails is an ongoing element of a full body assessment as you work through steps 3-9. 2. Skin, hair, and nails: Inspect for lesions, bruising, and rashes. Palpate skin for temperature, moisture, and texture. Inspect for pressure areas. Inspect...