Practicum 3

• What are you assessing during a Neurological assessment

  Level of consciousness

  Orientation:

  Person (have the patient state their name and date of birth on the wrist band, You verify)

  Place:

  Time (day, month, season)

  Situation (event…why are they here)
• What are you assessing when assessing skin?

  Skin Turgor on the dorsal hand or at the Clavicle

  assess skin color and temperature
• What are you assessing on the head

  Skin breakdown/pressure ulcers on the back of the head.

  Ears: Discharge

  Nose: discharge

  Mouth- wet moist tongue, lesions, sores, dentures

  PERRLA Pupils Equal Round Reactive to Light and Accommodating

  What is the size of the pupil and is it the same in each eye.

  Do pupils constrict & dilate simultaneously with and without light?  (pupillary reaction)

  Do the pupils constrict when looking near at an object? Do the pupils dilate when looking at a distant object?  (Accommodation)
• What are you assessing on the neck?

  Carotid pulse
• What shouldn't you do when assessing the carotid pulse

  DO NOT PALPATE BILATERLLY AT THE SAME TIME
• What are you assessing arms

  Color, Brachial and radial pulse, cap refill, hand strength bilaterally, hydration, test range of motion
• What are you assessing when assessing the chest

  Ask if it is ok to move the patient's gown

  listen to heart and lung

  inspect check

  listen to Apical pulse (PMI)
• Where is the Apical Pulse (PMI)PMI

  5th intercostal space/mid clavicular
• How do you assess Lung sounds?

  Start by the clavicle and end at the diaphragm

  10 movements on the front and back

  snake-like motion

  on the back, fan out as you go down
• What are assessing in the back

  Lung sounds, assess for would and pressure ulcers
• when assessing the abdomen

  Ask the patient if they can lift the patient's gown

  Inspect first

  Listen to bowel sounds. Begin in RLQ then RUQ, LUQ, and end with LLQ, listen for 5 to 34 seconds

  Palpate: is distention, firm or soft
• When assessing the legs

  Ask the patient if you can move their gown

  assess pulses: popliteal, posterior tibia, dorsal pedis (palpate the pulses Bilaterally)

  cap refill,

  check heels for pressure ulcers

  test food strength

  do they have edema
• What is the order of a head-to-toe

  Wash hands and put on gloves

  Provide privacy

  Identify yourself and properly identify the patient

  Neurological

  Vital signs

  skin

  head

  neck

  arms

  chest

  back

  abdomen

  Legs
• What are the types of drainage

  Serous, Sanguinuinous, Serosanguineous, Purulent
• What is Serous drainage

  composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery.
• What is Serosanguineous drainage

  mixture of serum and red blood cells. It is light pink to blood tinged.
• What is Purulent drainage

  is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.
• What is the open drain

  Penrose
• What is a Penrose Drain

  soft and flexible. This drain does not have a collection device
• How does Penrose drain?

  It promotes drainage passively, with the drainage moving from the area of greater pressure, in the wound or surgical site, to the area of less pressure, the dressing.
• What are the close drains

  Hemovac and Jackson-Pratt (JP)
• Hemovac and Jackson-Pratt drain

  Closed drainage systems consist of a drainage tube that may be connected to an electrical suction device or have a portable built-in reservoir to maintain constant low suction.
• What are you looking for in the appearance of a wound

  Location is described in relation to the nearest anatomic landmark, such as bony prominences. Document the size of the wound. Assess wounds for the approximation of the wound edges (edges meet) and signs of dehiscence or evisceration. Assess the color of the wound and surrounding area.
• What is Dehiscence

  the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.
• What is Evisceration


  the most serious complication of dehiscence