NSB103 Lecture Notes - Lecture 11: Mental Status Examination, Heart Sounds, Palpation
Week 11: Comprehensive Health Assessment
Legal Consideration:
- Document all interactions
- Confidentiality
- Report any disease
- Respect patient privacy
- Respect right to refuse assessment or treatment
- Ask permission
- Understand hospital policies and practices
- Understand your nursing code of conducts etc.
General Survey
- Physical presence- Age, body fat, stature motor activity; body breath and odours
- Psychological presence- mental status- dress, grooming, personal hygiene; mood/manner,
speech, facial expressions
- Presence of distress
- Pain
Primary Survey
- A – airway
- B – breathing
- C – circulation
- D – disability
- E – exposure
Vital Signs
- Temperature: 36.1- 37.1
- Pulse Rate: 60-100
- Respiration rate: 12-20
- Blood Pressure: 120/80
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Document Summary
Respect right to refuse assessment or treatment. Understand your nursing code of conducts etc. Physical presence- age, body fat, stature motor activity; body breath and odours. Psychological presence- mental status- dress, grooming, personal hygiene; mood/manner, speech, facial expressions. Focused gastrointestinal assessment: i(cid:374)spe(cid:272)t abdomen, aus(cid:272)ultate fo(cid:396) p(cid:396)ese(cid:374)(cid:272)e of (cid:271)o(cid:449)el sou(cid:374)ds, ge(cid:374)tl(cid:455) pe(cid:396)(cid:272)uss o(cid:448)e(cid:396) a(cid:271)do(cid:373)e(cid:374, lightl(cid:455) palpate ea(cid:272)h (cid:395)uad(cid:396)a(cid:374)t, assess fo(cid:396) (cid:396)e(cid:272)e(cid:374)t a(cid:374)d f(cid:396)e(cid:395)ue(cid:374)(cid:272)(cid:455) of (cid:271)o(cid:449)el (cid:373)o(cid:448)e(cid:373)e(cid:374)ts, dete(cid:396)(cid:373)i(cid:374)e f(cid:396)e(cid:395)ue(cid:374)(cid:272)(cid:455) of (cid:396)e(cid:374)al assess(cid:373)e(cid:374)t (cid:271)ased o(cid:374) patie(cid:374)t"s (cid:272)o(cid:374)ditio(cid:374) Focused renal assessment: measu(cid:396)e u(cid:396)i(cid:374)e output, o(cid:271)se(cid:396)(cid:448)e u(cid:396)i(cid:374)e fo(cid:396) (cid:272)olou(cid:396), offe(cid:374)si(cid:448)e s(cid:373)ell o(cid:396) p(cid:396)ese(cid:374)(cid:272)e of sedi(cid:373)e(cid:374)t, pe(cid:396)fo(cid:396)(cid:373) u(cid:396)i(cid:374)al(cid:455)sis, assess fluid (cid:448)olu(cid:373)e status, dete(cid:396)(cid:373)i(cid:374)e f(cid:396)e(cid:395)ue(cid:374)(cid:272)(cid:455) of (cid:396)e(cid:374)al assess(cid:373)e(cid:374)t (cid:271)ased o(cid:374) patie(cid:374)t"s (cid:272)o(cid:374)ditio(cid:374) Musculoskeletal assessment: o(cid:271)se(cid:396)(cid:448)e patie(cid:374)t"s a(cid:271)ilit(cid:455) to safel(cid:455) sta(cid:374)d, t(cid:396)a(cid:374)sfe(cid:396) a(cid:374)d (cid:373)o(cid:271)ilise. Note assistance necessary: o(cid:271)se(cid:396)(cid:448)e gait, i(cid:374)spe(cid:272)t a(cid:374)d palpate joi(cid:374)ts fo(cid:396) (cid:396)a(cid:374)ge of (cid:373)otio(cid:374). Note a(cid:374)(cid:455) pai(cid:374) o(cid:396) s(cid:449)elli(cid:374)g: assess (cid:373)us(cid:272)le st(cid:396)e(cid:374)gth. Co(cid:373)pa(cid:396)e the (cid:396)ight a(cid:374)d left of pai(cid:396)ed muscle groups.
