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Nursing assessment nursing process. This can be called the base or foundation of the nursing process.
is
important
in the whole
With a weak and incorrect nursing assessment, you might create also an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation. To prevent those kind of scenarios, we have created a cheat sheet on which you can print or copy to be used during your assessment.
FINDINGS When skin is pinched it goes to previous state immediately (2 seconds).With fair complexion.With dry skin Evenly distributed hair.With short, black and shiny hair.With presence of pediculosis Capitis. Smooth and has intact epidermisWith short and clean fingernails and toenails. Convex and with good capillary refill time of 2 seconds.
Rounded, normocephalic and symmetrical, smooth and has uniform consistency.Absence of nodules or masses. Symmetrical facial movement, palpebral fissures equal in size, symmetric nasolabial folds. Hair evenly distributed with skin intact.Eyebrows are symmetrically aligned and have equal movement. Equally distributed and curled slightly outward. Skin intact with no discharges and no discoloration.Lids close symmetrically and blinks involuntary. Transparent with capillaries slightly visible Shiny, smooth, pink Appears white. No edema or tenderness over the lacrimal gland and no tearing. Transparent, smooth and shiny upon inspection by the use of a penlight which is held in an oblique angle of the eye and moving the light slowly across the eye.Has brown eyes. Blinks when the cornea is touched through a cotton wisp from the back of the client. Black, equal in size with consensual and direct reaction, pupils equally rounded and reactive to light and accommodation, pupils constrict when looking at near objects, dilates at far objects, converge when object is moved toward the nose at four inches distance and by using penlight. When looking straight ahead, the client can see objects at the periphery which is done by having the client sit directly facing the student nurse at a distance of 2-3 feet. The right eye is covered with a card and asked to look directly at the student nurses nose. Hold penlight in the periphery and ask the client when the moving object is spotted. Able to identify letter/read in the newsprints at a distance of
Eyelashes Eyelids Bulbar conjunctiva Palpebral Conjunctiva Sclera Lacrimal gland, Lacrimal sac, Nasolacrimal duct
y y y y
Cornea
y
Corneal sensitivity
Pupils
Visual Fields
Visual Acuity
fourteen inches. She was able to read the newsprint at a distance of 8 inches. Ear and Hearing
y
Auricles
Color of the auricles is same as facial skin, symmetrical, auricle is aligned with the outer canthus of the eye, mobile, firm, non-tender, and pinna recoils after it is being folded. Without impacted cerumen. Voice sound audible. Able to hear ticking on right ear at a distance of one inch and was able to hear the ticking on the left ear at the same distance Symmetric and straight, no flaring, uniform in color, air moves freely as the clients breathes through the nares. Mucosa is pink, no lesions and nasal septum intact and in middle with no tenderness. Symmetrical, pale lips, brown gums and able to purse lips. With dental caries and decayed lower molars Central position, pink but with whitish coating which is normal, with veins prominent in the floor of the mouth. Moves when asked to move without difficulty and without tenderness upon palpation. Positioned midline of soft palate. Present which is elicited through the use of a tongue depressor. Positioned at the midline without tenderness and flexes easily. No masses palpated. Coordinated, smooth movement with no discomfort, head laterally flexes, head laterally rotates and hyperextends. With equal strength Non-palpable, non tender Not visible on inspection, glands ascend but not visible in female during swallowing and visible in males. Chest symmetrical
y y
Uvula Gag Reflex Neck Head movement Muscle strength Lymph Nodes y Thyroid Gland Thorax and lungs Posterior thorax
Spinal alignment
Breath Sounds y Anterior Thorax Abdomen Abdominal movements y Auscultation of bowel sounds Upper Extremities Lower Extremities Muscles Bones and Joints Mental Status Language Orientation Attention span Level of Consciousness Motor Function Gross Motor and Balance y Walking gait Standing on one foot with eyes closed Heel toe walking Toe or heel walking Fine motor test for Upper Extremities Finger to nose test Alternating supination and pronation of hands on knees Finger to nose and to the nurses finger Fingers to fingers Fingers to thumb Fine motor test for the Lower Extremities Pain sensation
Spine vertically aligned, spinal column is straight, left and right shoulders and hips are at the same height. With normal breath sounds without dyspnea. Quiet, rhythmic and effortless respiration Unblemished skin, uniform in color, symmetric contour, undistended. Symmetrical movements cause by respirations. With audible sounds of 23 bowel sounds/minute. Without scars and lesions on both extremities. With minimal scars on lower extremities Equal in size both sides of the body, smooth coordinated movements, 100% of normal full movement against gravity and full resistance. No deformities or swelling, joints move smoothly. Can express oneself by speech or sign. Oriented to a person, place, date or time. Able to concentrate as evidence by answering the questions appropriately. A total of 15 points indicative of complete orientation and alertness. E4V5M6
Has upright posture and steady gait with opposing arm swing unaided and maintaining balance. Maintained stance for at least five (5) seconds. Maintains a heel toe walking along a straight line Able to walk several steps in toes/heels. Repeatedly and rhythmically touches the nose. Can alternately supinate and pronate hands at rapid pace. Perform with coordinating and rapidity. Perform with accuracy and rapidity. Rapidly touches each finger to thumb with each hand. Able to discriminate between sharp and dull sensation when touched with needle and cotton.
Head
y y y
Head: The head of the client is rounded; normocephalic and symmetrical. Skull: There are no nodules or masses and depressions when palpated. Face: The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses.
o o o o o
The Bulbar conjunctiva appeared transparent with few capillaries evident. The sclera appeared white. The palpebral conjunctiva appeared shiny, smooth and pink. There is no edema or tearing of the lacrimal gland. Cornea is transparent, smooth and shiny and the details of the iris are visible. The client blinks when the cornea was touched. The pupils of the eyes are black and equal in size. The iris is flat and round. PERRLA (pupils equally round respond to light accommodation), illuminated and nonilluminated pupils constricts. Pupils constrict when looking at near object and dilate at far object. Pupils converge when object is moved towards the nose. When assessing the peripheral visual field, the client can see objects in the periphery when looking straight ahead.
When testing for the Extraoccular Muscle, both eyes of the client coordinately moved in unison with parallel alignment. The client was able to read the newsprint held at a distance of 14 inches.
o y
Neck:
The neck muscles are equal in size. The client showed coordinated, smooth head movement with no discomfort. The lymph nodes of the client are not palpable. The trachea is placed in the midline of the neck. The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible.
o o o
The spine is vertically aligned. The right and left shoulders and hips are of the same height.
The chest wall is intact with no tenderness and masses. Theres a full and symmetric expansion and the thumbs separate 2-3 cm during deep inspiration when assessing for the respiratory excursion. The client manifested quiet, rhythmic and effortless respirations.
Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no presence of heaves or lifts. The jugular veins are not visible. When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds.
o o
Abdomen: The abdomen of the client has an unblemished skin and is uniform in color. The abdomen has a symmetric contour. There were symmetric movements caused associated with clients respiration.
Extremities
y y y y
The extremities are symmetrical in size and length. Muscles: The muscles are not palpable with the absence of tremors. They are normally firm and showed smooth, coordinated movements. Bones: There were no presence of bone deformities, tenderness and swelling. Joints: There were no swelling, tenderness and joints move smoothly.