Assessment follow up notify the physician of all

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Unformatted text preview: s: As you converse with the patient assess: * Awake/ alert, asleep? * Skin color * Respiratory effort * Orientation to person, place, time * Communication/ speech * Respiratory effort and rhythm * On/ off O2 * Glasgow coma score * Pain At the head assess: * Skin color, temp, moisture and integrity * Incisions and dressings * Oral mucosa/ tongue * Skin tenting on forehead * Tremors * Pupils * Jugular/ subclavian CVL * NG/ Nasoduodenal tube At the upper extremities assess: * Skin color, temp, moisture and integrity * Incisions and dressings * Capillary refill * Radial pulses * Skin tenting on forearm * Edema * Periph IV/ PICC insertion sites * Tremors * Hand grasps * Muscle tone and strength * Casts At the chest/ back assess: * Skin color, temp, moisture and integrity * Incisions and dressings * Breath sounds * Respiratory rate, depth, rhythm and effort * Oxygen settings * Apical pulse * Apical/ radial deficit * Heart sounds At the abdomen assess: * Skin color, temp, moisture and integrity * Incisions and dressings * Nutritional intake * Nausea/ vomiting * Bowel movements * Distention/ ascites * Bowel sounds * PEG/ J tube site * Tube feedings * Stomas * Continence * Abdominal/ flank pain * Bladder distention, s/s of UTI * Urine output, color, characteristics * Urinary catheter At the genitalia/ buttocks: * Skin color, temp, moisture and integrity * Incisions and dressings * Femoral pulses * Sacral edema At the lower extremities assess: * Skin color, temp, moisture and integrity * Pedal and posterior tibial pulses * Edema * Muscle tone and strength * Incisions and dressings * Capillary refill * Tremors * Casts * Notify the Physician of abnormal findings of concern * Implement the nursing process * Analyze the data * Identify the appropriate nursing diagnoses. * Develop and implement a plan * Evaluate the outcomes An Easy Guide to Head to Toe Assessment © Mary C. Vrtis, Ph.D., RN, 2008 available from Cardiac Rhythm Assessment by ECG Sinus rhythm: Normal sinus rhythm (NSR) [P wave before every QRS, P -R interval < 0.20, rate is between 60 to 100] Sinus tachycardia [rate => 101] Sinus bradycardia [rate =< 59] Sinus arrhythmia [P wave before every QRS, but rate varies with respiration] Atrial dysrhythmias: Atrial fib* [atria of heart is fibrillating, ECG shows wavy line, conduct ion thru A-V node to ventricles is erratic] Atrial flutter with __:1 conduction block [atrial rate approx 300, ventricular (heart) rate 150 = 2:1, HR 75 = 4:1] Atrial fib/ flutter [atria mixture of flutter and fibrillation] Paroxysmal supraventricular tachycardia (PSVT) [sudden onset, very fast rates, narrow QRS, P wave absent or behind QRST] A-V Heart Blocks: First degree heart block [delayed conduction thru AV node, P-R interval > 0.20] Second degree A-V block, Mobitz I**[P-R interval lengthens until a QRS is absent, cyclic pattern with every X beat dropped] Second degree A-V block, Mobitz II*** [P-R interval is stable, no QRS after some P waves due to intermittent AV block] Third degree A-V block** [no relationship between P waves and QRS complexes due to complete bl ock at AV node] Paced Rhythms: Atrial-ventricular (AV) sequential pacing [spike before the P wave and spike before the QRS] 1:1? Yes No Ventricular pacing [pacing spike before the QRS only] 1:1? Yes No Demand pacing [heart rate is higher, pacemaker fires only if there is a delay in spontaneous activity]? Yes No Automatic internal defibrillator (IAD)? No Yes Has client felt it fire? No Yes, when _________________ Ectopic Beats: Ventricular premature beats (VPB, PVC) [an early, wide QRS, extra beat originating in the ventricle] Bigeminy [every other beat is a VPB] Trigeminy [every 3rd beat is a VPB] Quadrigeminy [every 4th beat is a VPB] Premature atrial beats (PAB, PAC) [an early, narrow QRS, extra beat originating in the atria, P wave shape may be different] Premature junctional beats (PJB) [an early, narrow QRS, extra beat originating above the A-V node, no P wave] Lethal dysrhythmias: Ventricular escape rhythm (also called idioventricular) [wide QRS complexes, HR @ ventricular intrinsic rate, 30 - 40] Ventricular tachycardia [wide QRS, tachycardic rates, minimal cardiac output due to ineffective pumping, cannot sustain life] Ventricular fibrillation [erratic line, ventricles are quivering, no pumping action, cardiac output is 0] *A fib with rapid response (HR > 100) increases myocardial oxygen needs and risk of LV failure is high, also high risk for PE . **Previously called Wenckebach. ***Mobitz II second degree and third degree block can result in life threatening bradycardia....
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This note was uploaded on 03/26/2013 for the course NURSING 1201 taught by Professor Smith during the Spring '12 term at Glendale Community College.

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