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PCCN: Chapter 1 - Assessment of
Progressive Care Patients and Their
Families
Why is assessment of acutely ill patients and their families essential? - ✔information obtained identifies immediate and future needs so a plan of care can be initiated Traditional approaches to Patient Assessment include: - ✔- include a complete evaluation of patient history
- comprehensive physical exam of all body systems Progressive care clinicians must balance: - ✔-need to gather data -prioritizing and providing care Collection of assessment data is obtained in: - ✔-phased or staged manner -consistent with pt care priorities What is the crucial element to developing competence in assessing progressive care patients? - ✔-consistent and systematic approach Discuss the importance of a consistent and systematic approach to assessment of progressive care pt and families? - ✔- helps avoid missing subtle signs or details that identify actual or potential problem -indicate a pt's changing status Assessments should first focus on (2): - ✔-patient (focal point of practitioner's attention) -technology (augments info obtained from direct assessment) What are the TWO standard approaches to assessing patients? - ✔-head-to-toe approach -body systems approach Most progressive care nurses use a (2): - ✔-combination systems approach -applied in a top-to-bottom manner Assessment of the progressive care patient begins (2) - ✔-moment nurse aware of pending admission/transfer -continues until transitioning to next phase of care The pre-arrival assessment helps the nurse (3): - ✔-paint an initial picture
- to anticipate physiologic and psychological needs -determine appropriate resources needed The information received in the prearrival phase is crucial because (2): - ✔-allows nurse to adequately prepare environment -meet specialized needs of pt/family When should the arrival quick check assessment be obtained? - ✔-immediately upon arrival to the unit What assessment acronym is used in the arrival quick check assessment? -
✔_"ABCDE"
Define what the letters in the assessment acronym, "ABCDE" represent. - ✔A = Airway B = Breathing C = Circulation, Cerebral Perfusion and Chief Complaint D = Drugs and Diagnostic tests E = Equipment The FOCUS of the quick check assessment is a quick overview of the: - ✔-adequacy of ventilation and perfusion -to ensure early intervention for life threatening situations -(obtaining a quick overview of the key life-sustaining systems) Why is the arrival quick check is ESSENTIAL because: - ✔-validates that basic cardiac and respiratory function is sufficient When is a comprehensive assessment done? - ✔As soon as possible The timing of the comprehensive assessment is dictated by: - ✔-degree of physiologic stability -emergent treatment needs When the patient is admitted directly to PCU from OUTSIDE the hospital, the comprehensive assessment includes: - ✔-an in depth assessment of PMH and social hx -complete physical exam of each body system If the patient is TRANSFERRED to PCU from another area in the hospital the comprehensive assessment includes: - ✔-review of admission assessment data -comparison to the current assessment The comprehensive assessment is VITAL because: - ✔- it influences successful outcomes -provides invaluable insight into proactive interventions What follows the conclusion of the comprehensive assessment? - ✔- Ongoing assessments begin Define: ongoing assessment - ✔-an abbreviated version of the comprehensive assessment that are more focused and driven by the stability of the pt What do the ongoing assessments determine? - ✔-TRENDS -response to therapy -identify new problems -changes from baseline Name the FOUR types of assessments performed: - ✔-pre-arrival assessment -arrival quick check assessment -comprehensive initial assessment -ongoing assessment Identify the assessment priorities for each of the four types of assessment: - ✔Pre-arrival = prepare environment Quick Check = validates basic cardiac/respiratory function
-diagnosis -reason for admission -pertinent history details -physiologic stability -gender & age -presence of invasive tubes & lines -medications being administered -ongoing treatments -pending or completed labs/diagnostic tests -isolation requirements Why is being prepared for isolation needs important? - ✔-prevents potentially serious exposures to patient, room- mates and HC workers What should be VERIFIED prior to the pt's arrival? - ✔-proper functioning of all bedside equipment From the moment the pt arrives in the PCU, what is IMMEDIATELY observed? - ✔- general appearance -assessment of "ABCDE" What type of 'needs' are addressed FIRST? - ✔-Urgent needs Identify actions that take place when pt first arrives in PCU? - ✔-seriousness of problems determined and addressed -connected to monitors & support equip -Rx being admin are verified -essential lab/diagnostic tests ordered List THREE ways the nurse can validate the pt is properly identified: - ✔-hospital wristband -personal ID -family ID When identifying pt allergies, what else must the nurse verify? - ✔-type of reaction that occurs -what, if any, treatment is used to alleviate the allergic response When a pt is transferred to the PCU, who is the LEADER of the receiving team? - ✔-the PCU nurse What are the responsibilities of the PCU nurse? - ✔-assumes responsibility for assessing the "ABCDE's" -directs team in completing delegated tasks Why is having a designated LEADER of the receiving team so critical? - ✔-prevents fragmentation of care -reduces possibility that vital assessment clues overlooked If preliminary assessment deviates from normal then: - ✔-interventions are immediately initiated BEFORE continuing with the arrival quick check assessment How does the nurse verify the patency of the pt airway? - ✔-have pt speak -watching chest rise or fall -both What INITIAL action is initiated if the airway appears
compromised? - ✔-verify the head positioned properly to prevent the tongue from occluding the airway What should the upper airway be inspected for before inserting an artificial airway? - ✔-blood -vomitus -foreign objectys What should the nurse ENSURE if a pt has an artificial airway such as a cricothyrotomy or tracheostomy? - ✔-airway is secured properly -note position and size markings Describe - ✔ Identify THREE characteristics of secretions, that should be assessed when suctioned from the airway? - ✔-amount -color -consistency Identify elements observed when assessing a pt's breathing status? - ✔-rate, depth, pattern -symmetry of breathing -effort -use of accessory muscles When a pt is on mechanical ventilation assess for: - ✔-whether breathing is in synchrony with the ventilator Identify THREE nonverbal signs of respiratory distress> - ✔-restlessness -anxiety -change in mental status Auscultate the chest for: - ✔-presence of bilateral breath sounds -quality of breath sounds -bilateral chest expansion During the arrival quick check assessment, where does auscultation of the chest usually take place? - ✔-anterior chest When chest tubes are present, assess for: - ✔-type (pleural or mediatsinal) -connected to suction (wall or water) -not clamped or kinked -functioning properly (FOCA & DOPE) Define mnemonic: FOCA - ✔-F = Fluid fluctuation with respirations -O = Output -C = Color of drainage (amount and character) -A = Air leak Define mnemonic: DOPE - ✔-D = Dislodgement -O = Obstruction -P = Pneumothorax
-complete blood count with platelets -coagulation studies -CXR -EKG At what time does the comprehensive assessment begin? - ✔-after completion of the "ABCDE's" If any component of the ABCDE's has not been stabilized & controlled, what happens next? - ✔-energy is focused FIRST, on resolving the abnormality -THEN, proceeding to the comprehensive admission assessment What are some possible pitfalls that can occur during handoff report? - ✔-safety gaps may occur -omission of pertinent information -miscommunication can result in pt care errors What is an example of a standardized handoff format? What is the advantage of using this format? - ✔-SBAR
- it can minimize potential for miscommunication Define mnemonic: SBAR - ✔-S = Situation -B = Background -A = Assessment -R = Recommendations What does the comprehensive assessment determine? - ✔-physiologic and psycho-social baseline -defines pt pre-event health status What does the comprehensive assessment include? - ✔-pt's medical history -brief social history -physical exam each body system Why should additional emphasis be placed on the PMH of patients who are elderly?
- ✔-frequently has multiple, co-existing illnesses -taking multiple prescriptive Rx & OTC
What elements of the social history must be addressed in patients who are elderly? - ✔-home environment -support systems -self-care abilities What MUST be taken into consideration when interpreting clinical findings in the elderly patient? - ✔-the coexistence of several disease processes + diminished reserves of body systems results in more RAPID PHYSIOLOGIC DETERIORATION When inquiring about the use and abuse of caffeine, alcohol, tobacco and other substances, questions are aimed at determining what? - ✔-the frequency, amount and duration of use Information revealed during the social history can be verified during the physical assessment by: -
✔-presence of needle track marks -nicotine stains on teeth and fingers -smell ETOH on breath Why should patients be asked about physical and emotional safety in their home environment? - ✔-to uncover potential domestic or elder abuse What are the primary body systems that aging effects? - ✔-Nervous -Cardiovascular/Circulatory -Respiratory -Renal -GI -Endocrine, Hematologic & Immunologic -Skin -Musculoskeletal -Psycho-social Identify specific effects aging has on the NERVOUS system. - ✔-diminished hearing and vision -ST memory loss -altered motor coordination -decreased muscle tone and strength -slower response to verbal and motor stimuli -decreased ability to synthesize new information -increased sensitivity to altered temperature states -increased sensitivity to sedation (confusion/agitation) -decreased alertness states -nerve cells transmit more slowly -increased incidence intracerebral hematomas (due to anticoagulant use) How does nerve cells that transmit more slowly effect the body of an older patient? - ✔-reduces reflexes -reduces sensation -problems with movement & safety -reduced pain perception and control Brain tissue atrophy results in the following: - ✔-stretching parasagittal bridging veins (making them more susceptible to rupture -additional space in cranial vault (that allows bleeding to accumulate before S/Sx of increased ICP present) -higher incidence of chronic subdural hematomas Identify THREE factors that increase bleeding tendancies in older adults: - ✔-anticoagulant therapy (Coumadin, Heparin, Lovenox) -antiplatelet therapy (ASA) -alcohol abuse How does alcohol abuse directly effect bleeding tendancies? - ✔-causes brain atrophy -causes liver damage that precipitates clotting problems Identify age related compromises to the CARDIOVASCULAR system. - ✔-increased effects of atherosclerosis of vessels/heart valves -decreased stroke volume with resulting decreased cardiac
-reduces tidal volume Following minor thoracic injuries, older patients experience higher complication rates with: - ✔-pulmonary edema -atelectasis -pneumonia When inserting an oral or nasal airway & when suctioning, use caution because: - ✔-mucosa is thinner in older adults -may be on anticoagulant therapy Elderly patients on anticoagulant therapy, requiring insertion of a nasopharyngeal or oropharyngeal airway are at greater risk for what complications? - ✔-swelling -bleeding -hemorrhage Define: hypercapnia - ✔-excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration Identify TWO examples of rheumatic conditions that can make intubating older patients more difficult. - ✔-arthritis -osteoporosis What specific effects can arthritis and osteoporosis have during intubation of older patients? - ✔-limited visualization of vocal chords (due to decreased mobility with the jaw thrust) -increased possibility of C-spine injury during instrumentation Identify age related compromises to the RENAL system. - ✔-decreased glomerular filtration rate -increased risk of fluid and electrolyte imbalances -decreased number of nephrons (limits the ability to concentrate the urine) -diminished sense of thirst (leads to dehydration) Identify age related compromises to the GI system. - ✔-increased presence of dentition problems (dentures) -decreased intestinal mobility -decreased hepatic metabolism -increased risk of altered nutritional states Identify age related compromises to the ENDOCRINE, HEMATOLOGIC & IMMUNOLOGIC system. - ✔-increased incidence of DM; thyroid D/O; anemia; -decreased antibody response & cellular immunity -thyroid function drops (slowing metabolism) -parathyroid levels rise (increasing risk osteoporosis) -increased incidence of metabolic syndrome (Type 2 DM) ( blunting effects of insulin) -aldosterone production drops (predisposing orthostatic hypotension and dehydration) Identify age related compromises to the SKIN. - ✔-decreased skin turgor (due to breakdown of elastin)
-increased capillary fragility & bruising -decreased elasticity -decrease thermoregulation -loss of SQ fat = thinning of the skin -decreased ability to sweat Define: thermoregulation - ✔impaired heat conservation, production and dissipation Identify situations that contribute to the risk of compromised thermo-regulation: - ✔-loss of SQ fat & thinning of skin -decreased ability to sweat -neurologic changes -chronic cardiac or thyroid conditions -poor nutrition -psychotropic medications -temperature extremes Identify environmental factors that cause skin to age. - ✔-lifestyle -diet -heredity -sun exposure -smoking -obesity -immobility Identify age related compromises to the MUSCULO-SKELETAL system. - ✔-older adults predisposed to C-injury -osteoporosis -changes in bone density -osteopenia -development of spinal stenosis -increasing rigidity C4-C6 levels -rigidity from neurologic D/O (Parkinson dx) -Kyphosis (limits C-range of motion) -fat and fibrous tissue replaces lean body mass -diminished force of contractile muscle -increased weakness and fatigue -poor exercise tolerance -slower, limited movement -slower & shorter gait, unsteadiness Define: osteoporosis - ✔-reduction in the quantity of bone or atrophy of skeletal tissue Define: osteopenia - ✔-decreased calcification or density of bone; -reduced bone mass Define: kyphosis - ✔-excessive outward curvature of the spine, causing hunching of the back Identify age related compromises to the PSYCHO-SOCIAL system. - ✔-difficulty falling asleep and fragmented sleep patterns
What assessment is the baseline standard for SCI, extremity trauma and epidural analgesia? - ✔-sensory testing When evaluating mental status, observe: - ✔-orientation to person, place and time -state understanding of what is happening
- eye contact
- pressured/muted speech -rate of speech What is a patient's rate of speech consistent with? - ✔-psychomotor status Cognitive impairments are exacerbated during an acute illness due to: - ✔-physiologic changes -Rx -environmental changes Identify common DIAGNOSTIC tests pertinent to the nervous system include: - ✔-serum electrolytes -urine electrolytes -urine osmolarity -urinary specific gravity -drug toxicology -ETOH level Identify the FOCUS of assessments of these body systems: - ✔-Nervous = evaluating the CNS -CV = evaluating central/peripheral perfusion -Resp = oxygenation & ventilation -Renal = function of kidneys & impact on fluid volume -GI = nutritional & fluid status -Endocrine = hormonal regulation -Hematologic = oxygen-carrying capacity of blood and clotting mechanisms -Immunologic = fighting infection -Integumentary = intactness of the skin If a patient is on telemetry monitoring, assess the ECG for: - ✔-T-wave abnormalities -ST segment changes -determine the PR, QRS, and QT intervals -abnormalities/indications of myocardial damage -electrical conduction problems -electrolyte imbalances If treatment decisions will be based on the cuff pressure, which are is used? - ✔-the pressure is taken in BOTH arms A difference of how many mmHg between a cuff BP and an arterial line pressure, require a decision to be made as to which pressure is the most accurate and will be followed for future treatment decisions? - ✔-10 - 15 mmHg When assessing the skin, INSPECT: - ✔-color -temperature -nail color
-capillary refill -edema When evaluating the color and temperature of the skin, emphasis is placed on observing the: - ✔-lips -mucous membranes -distal extremities Name THREE areas where dependent edema frequently occurs: - ✔-feet -ankles -sacrum AUSCULTATE heart sounds for: - ✔-S1 and S -quality, intensity and pitch -presence of extra heart sounds (murmers, clicks, rubs) -any changes with RR or pt position PALPATE the peripheral pulses for: - ✔-amplitute -quality Identify common DIAGNOSTIC tests pertinent to the cardiovascular system include:
- ✔-electrolyte levels -CBC -coagulation studies -lipid profiles -drug levels of commonly used CV medications What are the THREE most common cardiac enzyme levels drawn for complaints of chest pain or suspected chest trauma? - ✔-troponin -creatine kinase MB -B-natruretic peptide Identify FOUR reasons why a 12 lead ECG might be ordered? - ✔-complaints of chest pain -irregular rhythms -suspected myocardial bruising -baseline What TWO questions should a nurse ask if continuous infusions of medications, such as antiarrhythmics, are being administered? - ✔-ensure infused through appropriately sized vessel -compatible with any piggybacked IV solutions INSPECTION of the respiratory system assessment includes: - ✔-rate, rhythm -symmetry chest wall movement -productive cough/secretions suctioned > color, amount and consistency -trachea midline or shifted -thoracic cavity shape -AP diameter -structural deformities (kyphosis or scoliosis) PALPATION of the respiratory system assessment, includes: -
-amount and characteristics of drainage -any leakage around drainage tube Identify common DIAGNOSTIC tests pertinent to the renal system: - ✔-urinalysis -serum electrolyte levels -blood urea nitrogen (BUN) -creatinine -urinary and serum osmolarity INSPECTION of the abdomen includes: - ✔-overall symmetry -contour (flat, round, protuberant, distended) -discoloration or straie What FOUR factors are used to evaluate the nutritional status of a patient? - ✔-weight -muscle tone -condition of oral mucosa -lab values (serum albumin; transferrin) AUSCULTATION of the abdomen includes: - ✔-bowel sounds in all four quadrants -characteristics and frequency -adventitious sounds (friction rubs, bruits, hums) How are BOWEL SOUNDS auscultated? - ✔-clockwise fashion in all four quadrants -note frequency -presence/absence of sounds What are the FOUR ratings for bowel sounds? - ✔-absent -hypoactive -normal -hyperactive Before noting ABSENT bowel sounds, a quadrant should be auscultated for how long? - ✔-60 - 90 seconds PALPATION of the abdomen helps determine: - ✔-areas of fluid -rigidity -tenderness -pain -guarding (rebound tenderness) Why do you auscultate BEFORE palpation? - ✔-palpation may change frequency and character of the peristaltic sounds In a patient with GI drainage tubes, OBSERVE: - ✔-location -function -characteristics of drainage -validate proper placement -ensure patency -drainage/leakage around tubes INSPECT emesis and stool for: -
✔-occult blood INSPECT ostomies for: - ✔-location -color of stoma -peristomal skin condition -type of drainage Identify common DIAGNOSTIC tests pertinent to the hematologic system: - ✔-evaluation of RBC's -coagulation studies Diminished RBC's may affect: - ✔-oxygen-carrying capacity of the blood Identify common S/Sx of anemia (diminished RBC's): - ✔-pallor -cyanosis -light-headedness -tachypnea -tachycardia Insufficient clotting factors are evidenced by: - ✔-bruising -oozing from puncture sites/mucous membranes -overt bleeding Identify common DIAGNOSTIC tests pertinent to the immunologic system: - ✔-white blood cells (WBC's) -differential counts List additional things that can be indicative of underlying infection? - ✔-puncture sites/mucous membranes for oozing drainage -inflamed/reddened areas -spiking or persistent low grade temp INSPECTING the skin involves: - ✔-head-to-toe, A - P, & between skin folds skin integrity -color, temp, turgor -rashes, striae, discoloration, scars, lesions -abrasions, pressure ulcers, wounds -note size, depth, presence/absence of drainage Name factors that can affect communication: - ✔-culture -developmental stage -physical condition -stress -perception -neurocognitive deficits -emotional state -language skills What non-verbal clues can provide important information about the patient? - ✔-body gestures -facial expressions -eye movements -involuntary movements -changes in HR,BP and RR Name the TWO ways anxiety is exhausting. -
-frequent requests for pain Rx Name some common objects of fear that influence a patient's ability to cope. - ✔-treatments -procedures -pain -separation List some of the specific fears associated with the dying process. - ✔-unknown -loneliness -loss of body -loss of self-control -suffering -pain -loss of identity -loss of everyone loved by patient Name the phases of the grieving process. - ✔-denial -shock -anger -bargaining -depression -acceptance Define: advance directive - ✔-a physician order for life sustaining treatment (POLST) When does transition or discharge planning start? - ✔-arrival of the patient to PCU Identify FIVE situations in which an ongoing assessment should occur: - ✔-caregivers change -before/after major procedure -before/after transport off the floor -deterioration in physiologic or mental status initiation of any new therapy
