HNN114 Lecture Notes - Lecture 8: Capillary Refill, Angina Pectoris, Dorsalis Pedis Artery
HNN114
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ABDOMINAL ASSESSMENT
QUESTIONS TO ASK:
- How are you feeling today? (Start with a general open ended question)
- What kind of medications do you take?
- Do you have any food intolerances? What happens when you eat them?
- How would you rate the pain 1-10? What does it feel like? Where is it located?
- Have you experienced nausea or vomiting recently?
- How often do you have bowel movements?
- Have you or family members had a history of GI issues?
1. Hand hygiene
2. Introduce self to patient
3. Provide privacy and sanitise hands
4. Ask appropriate questions and history (following hospital protocol and assessments)
5. Perform obs (say which ones you would perform, which ones are relevant and why they are
relevant)
6. Ask if you can expose their chest area and put them in supine position
7. Get pt in supine position
8. Identify 4 anterior quadrants (umbilicus as centre point)
9. Inspect anterior abdomen
10. Identify symphysis pubis, xiphoid process and umbilicus
11. Look at symmetry of abdomen, concave or convex? Smooth or protrusions? Hair distribution?
Rashes or lesions? Distended?
12. Auscultate each quadrant, in the order RLQ, RUQ, LUQ, LLQ. Listen for normal and abnormal bowel
sounds
13. Percuss the abdomen, to determine abnormal masses by hearing the sounds it produces
14. Palpate the abdomen, begin with light and determine any tenderness, abnormal masses and
distension
15. Document all findings
16. What is one potential problem for this patient?
POTENTIAL NURSING PROBLEMS:
- Constipation
- Altered body image
- Pain
- Nutritional deficit or decreased appetite
- Nausea/vomiting
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- Dehydration
THESE COULD BE RELATED TO…
- Diarrhoea or constipation
- Celiac disease or food intolerance
- Pregnancy
- Issue with a particular organ
RESPIRATORY ASSESSMENT
QUESTIONS TO ASK:
- How are you feeling today? (Start with a general open ended question)
- What kind of medications do you take?
- Is there any history of respiratory conditions or issues in your family?
- Do you feel short of breath often? What usually causes this feeling?
- Describe any pain in the chest you have when breathing?
- Do you have asthma?
- Do you smoke, and if so how often?
- Have you experienced any change in smell?
- When did the coughing begin and when did it start?
17. Hand hygiene
18. Introduce self to patient
19. Provide privacy and sanitise hands
20. Ask appropriate questions (following hospital protocol and assessments)
21. Put pt in sitting position
22. Perform obs (say which ones you would perform, which ones are relevant and why they are
relevant)
23. Ask if you can expose their chest area
24. What are the landmarks you need?
25. Note any visible lumps or lesions or moles on their skin
26. Look for tracheal symmetry/straightness
27. Rate and rhythm of breathing and use of accessory muscles
28. Check their skin colour and temperature (warm and perfused)
29. Observe symmetry of rise and fall of the chest
30. Note the ratio of the surrounding chest (checking the transverse diameter is twice the width of the
anterior/posterior chest – checking for barrel chest)
31. Check for tenderness or pain
32. Place thumbs at centre of chest and ask patient to breath in and out to check for even respiratory
exertion (ask them to breathe in and out)
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HNN114
HURDLES
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33. Auscultate next
34. Use the diaphragm of the stethoscope and ask them to take deep breaths with their mouth open
35. Listen to the mid-zones and bases respectively by moving your stethoscope over the mid clavicle
line at the 2nd 4th 6th intercostal space, and over the 8th at the anterior axillary line.
36. Listen to both left and right sides of the chest
37. Listen to the posterior chest and ask patient to lean forward and fold arms
38. Listen to both sides and follow the scapular at the 1st 3rd 5th and 7th intercostal spaces
39. Clean and put away equipment
40. Palpate chest and get them to say 99 or blue moon
41. Perform hand hygiene
42. Document findings
43. What is at least one potential problem?
POTENTIAL NURSING PROBLEMS:
- Altered breathing pattern
- Ineffective airway clearance
- Risk for airway occlusion
- Impaired gas exchange
- Tissue hypoxia (inadequate oxygen for metabolic requirements)
THESE COULD BE RELATED TO…
- Exacerbation of Asthma
- Upper Respiratory Tract Infection (URTI)
- Chest infection
- Respiratory failure
CARDIOVASCULAR ASSESSMENT
QUESTIONS TO ASK:
- How are you feeling today? (Start with a general open ended question)
- What kind of medications do you take?
- Do you have any history of cardiac issues or heart attacks in you family?
- How long have you had chest pain for? What does it feel like?
- Have you experienced any fatigue?
- Ho has the fatigue ou’e epeieed affeted ou life?
- Do you have any swelling in your legs or arms?
- Have you experienced any leg cramps recently? Describe what they feel like?
- Have you noticed any change in your skin colour recently? Such as redness or blueness?
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