![]() nerve : Have the patient close their eyes and place something with a pleasant smell under the Okay” patient breathe out of it and do the same for the other. Then have the patient close one nostril and have the Breath out the other, and vice versa. “I’m gonna have you a clued one side of the nostril. Use a penlight to shine inside the nose and look for any lesions, redness, or polyps Drainage (ask patient: “ Are you have any trouble with your nose? Are you having any discharge or anything like that?”) Symmetrical (midline, look at septum for any deviation) Apple, banana” Repeat this for the other ear “Cat, dog”. “ I’m going to occlude your one ear and whispering two words and you have to repeat them back. Test the hearing by occluding one ear and whispering two words and have the patient repeat them back. O Aniscoria : Are the pupils equal in size. O Strabismus : Do the eyes line up with another? Is the conjunctiva pink NOT red/drainage and swollen? Ask Pt, “ Look up”. Inspect the eyes, eye lids, pupils, sclera, and conjunctiva Palpate the frontal and maxillary sinuses for tende here, and you tell me if you feel any pain” rness: patient will pressure but should not feel pain: ”I put my fingers with pressure on your sinuses right Palpate the temporomandibular joint for grating or clicking: Have the patient “ open and close the mouth” and feel for any grating sensation or clicking. Then have the patient try to open the mouth against resistance: “ Open your mouth against resistance”. ![]() Have the patient bite down and feel the masseter muscle and temporal muscle: “ Please, bite down for me”. nerve : This nerve is responsible for many functions and mastication is one of them. Inspect the hair for any infestations: lice, alopecia areata (round abrupt balding in patches), nevus on the scalp etc. Skin breakdown (especially on the back of the head in immobile patients)? Palpate the cranium and inspect the hair for infestations, hair loss, masses indentations, skin breakdown or abnormalities: nerve: close your eyes tightly for me? Open them up, now sm have the patient close their eyes tightly, smile, ile for me, frown, and pop up your cheeks.” frown, puff out cheek. ![]() Are the facial expressions symmetrical (no involuntary movements)? This can happen in Bell’s palsy or stroke. no drooping of the face on one side (eyes or lips). Is the head an appropriate size for the body? Inspect the overall appearance of the face (are the eyes and ears at the same level)? Overweight 25-29 Obesity class 1 is 30-34 Obesity class 2 is 35-39. Less than 18 is underweight greater than 30 is obese. Hypertension Stage 2 - SBP: ≥140 or DBP: ≥90 mm Hg Collect their height/weight, BMI – body mass index: multiply the height (cm) by itself and divide by the weight (kg). Hypertension Stage 1 - SBP: 130-139 or DBP: 80-89 mm Hg Normal heart rate in an adult is 60-100 beats per minute. If the heart rate is irregular count for 1 full minute. Count the heart rate (if regular) for 30 seconds and multiply by 2.It is located in the wrist, right below the thumb along the radial bone.Use the first three fingers of your hand and find the radial artery. Radial (the most commonly used in the adult) You can count a heart rate in various locations, such as: A normal oxygen saturation is 95% to 100%. A normal temperature in adults is: 97’F to 99’F (36 ‘C to 37 ‘C) and a temperature greater than 100’F is a fever. Remember: axillary and temporally will read 1 degree LOWER than an oral temperature, and temperatures taken in the rectum and ear will reading 1 degree HIGHER than an oral temperature. Taking a Temperature: Mouth (oral) Armpit (axillary) Forehead (temporal) Rectum (rectal) Ear (tympanic) Collect vital signs: heart rate, blood pressure, temperature, oxygen saturation, respiratory rate, and for pain level ask: “Ben, are you having any pain on a scale 0 to 10? 0 no pain at all, and 10 intending the worst pain you’ve ever had.” Alert&Oriented times x “ Who is the President of the United States ?”. If answers all questions: “ Can you tell me what we’re doing here today?”. Do you want me to call you Ben or Mr? “ “Ben, can you tell me where you at?”. Ask: “Say your first and last name for me?. Is that okay with you?” Look at armbands – identify the right patient and assess neuro status. I need to perform a head-to-toe assessment. Head to Toe Assessment: Provide privacy, perform hand hygiene, introduce yourself to the patient, and explain to the patient that you need to conduct a head-to-toe assessment “Hello, My name is _ and I’m going to be your nurse today.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |