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General Assessment (Physical assessment)

General Assessment (Physical assessment)

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Study Tools For General Assessment (Physical assessment)

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Outline

Overview

  1. The general assessment includes things you can observe on initial encounter with the patient
  2. It requires some interview, but very little hands-on assessment

Nursing Points

General

  1. Information to be gathered
    1. Alertness
    2. Patient identifiers
    3. Hygiene
    4. Signs of distress
    5. Emotions
    6. Affect
    7. Posture
    8. Skin appearance
    9. Sensory deficits (generally)
      1. Hearing
      2. Speech
      3. Vision
    10. Pain/general feeling
    11. Full set of vital signs

Assessment

    1. Recommended order of actions + what will be assessed with those actions
      1. Walk in the room
        1. Is the patient awake/alert?
        2. If not – call name, then gently shake, then increasingly noxious stimuli to wake
      2. Introduce yourself to the patient
        1. Can they hear/see you?
        2. How do they respond?
      3. Obtain 2 patient identifiers
        1. How is their speech quality?
        2. Do they seem confused?
        3. Are there any barriers to communication?
      4. Ask the patient how they are feeling
        1. How is their mood?
        2. Is their affect appropriate?
        3. Are they in pain?
      5. Assess general appearance
        1. How is their hygiene? Do they appear unkempt?
        2. Do they appear to be in distress?
          1. Rapid breathing
          2. Grimacing
          3. Restlessness
        3. How is their skin color, on first glance? Jaundiced? Cyanotic? Pale? Flushed?
        4. Are they sitting upright with good posture?
      6. Take a full set of vital signs
    2. Abnormal findings
      1. Inappropriate affect
        1. If the patient reports one emotion/mood, but their facial expressions show another
      2. Unconscious – see neuro assessment
      3. Signs of distress
        1. Rapid abnormal breathing
        2. Grimacing
        3. Restlessness
        4. Crying
      4. Abnormal skin colors
        1. Jaundice – liver
        2. Cyanosis – oxygen
        3. Pallor – perfusion
        4. Flushed – pain, inflammation, fever, etc.

Nursing Concepts

  1. If you note any signs of distress, stop your assessment and intervene before continuing
  2. If you note any extremely abnormal vital signs, investigate and report your findings before continuing
  3. If you note any communication barriers, implement alternative options before continuing
    1. Translator
    2. Writing pad
    3. Picture board
    4. Etc.
  4. Make note of any abnormal findings so that you can document them with your assessment later

Patient Education

  1. At this stage, inform the patient that you will be doing a full head to toe assessment, what that entails, and why
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Transcript

In this video we’re going to talk about the general portion of your head to toe assessment. This is the first 2 minutes of interaction with your patient and it can tell you a LOT of information before you even lift a finger to assess them!
The first thing you’ll do is walk in the room and introduce yourself to your patient.

You’ll already be noticing their level of alertness, general appearance, posture, etc. Then you’re gonna ask for your 2 patient identifiers. If they give you correct answers, you know they’re likely not confused, they can hear you, and you can assess their speech quality as well.

Then, ask them how they’re feeling or if they’re in any pain. This is a huge part of the assessment. If the patient says “I feel great”, but they’re tearful and look upset – we know something’s off. So we can assess their emotions and whether or not their affect is appropriate based on what they’re telling us.

We also can observe if they’re in any distress – how’s their breathing? Are they grimacing? Do they visibly look uncomfortable. We can see the patient here looks nice and calm, isn’t breathing heavy, and doesn’t look like she’s in any distress.

While you’re talking to them, make sure you’re looking at their general posture, are they sitting upright? How’s their hygiene? Do they appear to be unkempt? And, of course, we can see their basic skin color – looking for jaundice, cyanosis, paleness, or if they seem flushed. This patient looks tan with a normal skin tone for her ethnicity, so that’s a normal finding. Once you’ve completed your observations, take a full set of vital signs.

Big points to note here – if you note any distress, stop your assessment and intervene. If you have any abnormal vital signs, stop your assessment and address them. If there are any communication barriers to overcome, make sure you do that before you continue. And, of course, make note of any abnormal findings so that you can document them later.
So that’s your general health assessment, make sure you watch the other health assessment videos and you’ll be an expert at a full head to toe assessment in no time. Now, go out and be your best self today. And, as always, happy nursing!

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Nursing Clinical 360

With the rapid expansion of the COVID-19 pandemic many schools, instructors and students are left wondering what just happened?Students can’t access the tools and onsite clinical help they desperately need and instructors are trying to piece together online learning that prepares their students for success.It is because of this uncertainty and abrupt change that we have developed the Nursing Clinical 360 Course.Featuring:38 Highly Detailed Nursing Skills Video Lessons18 Health Assessment Lessons26 IV Skills Videos42 Case Studies30+ Care PlansWe want to give students the practical knowledge they need to feel confident going into a clinical or practical situation, as well as give instructors a concise library of online resources to handle the sudden demand for distance learning.

Course Lessons

1 - Head to Toe and Health Assessment
Intro to Health Assessment
Barriers to Health Assessment
The 5-Minute Assessment (Physical assessment)
Adult Vital Signs (VS)
Pediatric Vital Signs (VS)
General Assessment (Physical assessment)
Integumentary (Skin) Assessment
Neuro Assessment
Head/Neck Assessment
EENT Assessment
Heart (Cardiac) and Great Vessels Assessment
Thorax and Lungs Assessment
Abdomen (Abdominal) Assessment
Lymphatic Assessment
Peripheral Vascular Assessment
Musculoskeletal Assessment
Genitourinary (GU) Assessment
2 - IV Insertion
Supplies Needed
Using Aseptic Technique
Selecting THE vein
Tips & Tricks
IV Catheter Selection (gauge, color)
IV Insertion Angle
How to Secure an IV (chevron, transparent dressing)
Drawing Blood from the IV
Maintenance of the IV
IV Complications (infiltration, phlebitis, hematoma, extravasation, air embolism)
Needle Safety
IV Drip Therapy – Medications Used for Drips
IV Drip Administration & Safety Checks
Understanding All The IV Set Ports
Giving Medication Through An IV Set Port
How to Remove (discontinue) an IV
IV Placement Start To Finish (How to Start an IV)
Bariatric: IV Insertion
Dark Skin: IV Insertion
Tattoos IV Insertion
Geriatric: IV Insertion
Combative: IV Insertion
Tips & Advice for Newborns (Neonatal IV Insertion)
Tips & Advice for Pediatric IV
3- Nursing Skills
Nursing Skills (Clinical) Safety Video
Bed Bath
Linen Change
PPE Donning & Doffing
Sterile Gloves
Mobility & Assistive Devices
Spinal Precautions & Log Rolling
Restraints
Starting an IV
Drawing Blood
Blood Cultures
Central Line Dressing Change
Inserting a Foley (Urinary Catheter) – Female
Inserting a Foley (Urinary Catheter) – Male
Trach Suctioning
Trach Care
Inserting an NG (Nasogastric) Tube
NG (Nasogastric)Tube Management
NG Tube Med Administration (Nasogastric)
Stoma Care (Colostomy bag)
Wound Care – Assessment
Wound Care – Selecting a Dressing
Wound Care – Dressing Change
Wound Care – Wound Drains
Pill Crushing & Cutting
EENT Medications
Topical Medications
Drawing Up Meds
Medications in Ampules
Insulin Mixing
SubQ Injections
IM Injections
IV Push Medications
Spiking & Priming IV Bags
Hanging an IV Piggyback
Chest Tube Management
Pressure Line Management
4- Nursing Care Plans
Purpose of Nursing Care Plans
How to Write a Nursing Care Plan
Using Nursing Care Plans in Clinicals
Nursing Care Plan (NCP) for Abdominal Pain
Nursing Care Plan (NCP) for Acute Respiratory Distress Syndrome
Nursing Care Plan (NCP) for Alcohol Withdrawal Syndrome / Delirium Tremens
Nursing Care Plan (NCP) for Alzheimer’s Disease
Nursing Care Plan (NCP) for Angina
Nursing Care Plan (NCP) for Aortic Aneurysm
Nursing Care Plan (NCP) for Appendicitis
Nursing Care Plan (NCP) for Arterial Disorders
Nursing Care Plan (NCP) for Asthma
Nursing Care Plan (NCP) for Atrial Fibrillation (AFib)
Nursing Care Plan (NCP) for Benign Prostatic Hyperplasia (BPH)
Nursing Care Plan (NCP) for Cardiogenic Shock
Nursing Care Plan (NCP) for Cardiomyopathy
Nursing Care Plan (NCP) for Cholecystitis
Nursing Care Plan for Cirrhosis (Liver)
Nursing Care Plan (NCP) for Congestive Heart Failure (CHF)
Nursing Care Plan (NCP) for Constipation / Encopresis
Nursing Care Plan (NCP) for Diverticulosis / Diverticulitis
Nursing Care Plan (NCP) for Eating Disorders (Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder)
Nursing Care Plan (NCP) for Endocarditis
Nursing Care Plan (NCP) for Dehydration & Fever
Nursing Care Plan (NCP) for Gestational Hypertension, Preeclampsia, Eclampsia
Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed
Nursing Care Plan (NCP) for Heart Valve Disorders
Nursing Care Plan (NCP) & Interventions for Increased Intracranial Pressure (ICP)
Nursing Care Plan (NCP) for Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease)
Nursing Care Plan (NCP) for Leukemia
Nursing Care Plan (NCP) for Mood Disorders (Major Depressive Disorder, Bipolar Disorder)
Nursing Care Plan (NCP) for Myocardial Infarction (MI)
Nursing Care Plan (NCP) for Neutropenia
Nursing Care Plan (NCP) for Pancreatitis
Nursing Care Plan (NCP) for Parkinson’s Disease
Nursing Care Plan (NCP) for Peptic Ulcer Disease (PUD)
Nursing Care Plan (NCP) for Schizophrenia
Nursing Care Plan (NCP) for Seizures
Nursing Care Plan (NCP) for Spinal Cord Injury
Nursing Care Plan (NCP) for Systemic Lupus Erythematosus (SLE)
Nursing Care Plan (NCP) for Vomiting / Diarrhea
Nursing Care Plan (NCP) for Acute Kidney Injury
Nursing Care Plan (NCP) for Hypovolemic Shock
Nursing Care Plan (NCP) for Osteoporosis
Nursing Care Plan (NCP) for Congenital Heart Defects
Nursing Care Plan (NCP) for Diabetic Ketoacidosis (DKA)
Nursing Care Plan (NCP) for Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Nursing Care Plan (NCP) for Addison’s Disease (Primary Adrenal Insufficiency)
Nursing Care Plan (NCP) for Rheumatoid Arthritis (RA)
Nursing Care Plan (NCP) for Disseminated Intravascular Coagulation (DIC)
Nursing Care Plan (NCP) for Diabetes Insipidus
Nursing Care Plan (NCP) for Acquired Immune Deficiency Syndrome (AIDS)
Nursing Care Plan (NCP) for Lymphoma (Hodgkin’s, Non-Hodgkin’s)
Nursing Care Plan (NCP) for Thrombocytopenia
Nursing Care Plan (NCP) for Sickle Cell Anemia
Nursing Care Plan (NCP) for Bronchiolitis / Respiratory Syncytial Virus (RSV)
Nursing Care Plan (NCP) for Hyperthyroidism
Nursing Care Plan (NCP) for Post-Traumatic Stress Disorder (PTSD)
Nursing Care Plan (NCP) for Glomerulonephritis
Nursing Care Plan (NCP) for Neonatal Jaundice | Hyperbilirubinemia
Nursing Care Plan (NCP) for Renal Calculi
5- Nursing Concept Maps
Concept Map Course Introduction
Coronary Artery Disease Concept Map
COPD Concept Map
Asthma Concept Map
Pneumonia Concept Map
Bowel Obstruction Concept Map
Gastrointestinal (GI) Bleed Concept Map
Congestive Heart Failure Concept Map
Hypertension (HTN) Concept Map
Breast Cancer Concept Map
Amputation Concept Map
Sepsis Concept Map
Stroke Concept Map
Depression Concept Map