Nurses examine each patient each shift. Since I'm in neuro, I stress the neuro status. Does the person know his or her own name? The full name, or just the first name? What about family members who may be in the room? Does he know what year it is, who the president is? If the person has been in hospital for any length of time, I give them a little bit of slide-room in that one. It's VERY difficult to keep track of what day it is when you've been in hospital.
Does the patient know in general what's going on? Can she tell me what town she lives in? Does he or she seem to have a grasp of the seriousness of his or her condition? Does he have an idea of what the plan is for today and for the time he's in hospital? Does he have appropriate questions, or is he passive and awaiting whatever is going to happen?
I ask if the patient has any pain. This can be a tricky question for someone in hospital to answer, especially if there is any neuro deficit. If I'm not sure the person understands the question, I ask specifically: Does your head hurt? Does your stomach ache? Are you nauseated? Do you feel your head is spinning? Do you feel short of breath (Smothered)? Does your chest hurt, do your legs ache? And so on....
Does the patient have good control of his extremities? Can he grip my hands equally with his? Can he move his arms and legs normally? How strong are his extremities, compared with each other?
I have to know if he has sensation in all his extremities. If someone askes you if you have any numbness or tingling anywhere, you'd probably think you'd be able to answer that! But you might be surprised. Sometimes a patient will deny numbness, but if I touch left great toe and right great toe and ask if this feels exactly the same, it may turn out the left one is actually partially numb.
How's the circulation going down those legs (and getting back up) Is there swelling there? Swelling is actually part of the cardio-vascular system check, but a neuro problem often does cause swelling. So. . . If there's swelling, is it causing damage downstream? Reflexes? If the person is isn't moving around for me, if I stroke his sole briskly, which direction do his toes twitch, if at all. If I rub his sternum with my finger, will he wake up a little bit? If I press on his nailbed, will he withdraw from that?
Are his eyes in a neutral position or are they always held to one side? Do they track together? I shine a light in his eyes -- do the pupils react to light? Quickly? Equally?
I look to see if a person's face is symmetrical, and if it moves appropriately when he talks to me. I ask the patient to poke his or her tongue out at me. I'm looking to see what color his tongue is, and if it comes out midline or deviates from the center.
Some of the requests sound silly. I might ask you to put your arms out in front of you like you're superman taking off, and close your eyes.
All of my questions have at least two purposes. First, of course, I need to know the answer to the question, I need to see what it is I've asked you to show me. The second purpose is to see how well you understand that I am saying. Does the concept "Hold up two fingers" make sense to you, as well as do you have the strength to hold up two fingers? Can you understand me, but not talk to me? Or is this all beyond comprehension?
Skin is the next thing I look at. If there's been surgery, I check the site out. It kind of goes without saying, what I'm looking for here. I also check for rashes, if the skin is warm and the correct color. If the person is old, infirm, or has been in hospital for a while, I especially look at the person's bottom, heels and hips for skin breakdown.
I'll feel a person's pulse in her wrist, and compare it to what I heard when I listen to the heart with my stethoscope. I listen for rhythm and any sounds that are unusual. I look at a person's lips and tongue for paleness or blueness (at the same time I'm asking to see the tongue stick out) to see if oxygen is being circulated. I look at the extremities to see if the skin is warm and if it has blotches that indicate poor circulation.
I listen to the person breathe. I put my stethoscope near the center of the chest to listen for bronchial sounds, then I move out and down. The right lung has three lobes, the left only has two. Did you ever notice that the doctor or nurse asks you to take three deep breaths when she's listening on the right and only twice when she's listening to your left? That's why. If you're a heavy smoker, I'll be able to tell without asking you. Smokers sound musty. That's the only way to describe it. A person with a little bit worse problem sounds coarse. As problems get more severe, you can hear wheezes, crackles, and a wet sound at the worst end of the scale.
Then I listen to your tummy. I want to listen to bowel sounds. This is especially important after any kind of surgery. Even if you've just had surgery on your hand, the after-effects of the anesthesia, any pain medications you've had, can cause your digestion to slow down. If you start eating too soon, before your bowels start gurgling again, you'll be nauseated at the least and perhaps develop an ilius at the worst. An ilius is where a part of the intestines shut down entirely, and nothing moves down past the blockage. That's icky!
Some institutions chart by exception, and some require a narrative for every part of every assessment. If you chart by exception, this means that you have some sort of pre-set norms, and you only have to write a narrative note about anything that doesn't meet the norm. Here would be a narrative note for someone who was perfectly fine (and would definitely NOT be in hospital) if I had to write the narrative note:
Pt AOX3, PERLLA, MAEW, Skin WDI, HR regular, NSR s ectopies, LS CTA, abd soft, flat, BS + X 4 quads, voiding s problem. 0 c/o voiced, will monitor.
Pt = patient
AOX3 = alert, oriented times 3 (person, place, time)
PERRLA = pupils equal, round, reactive to light and accommodate to distance
MAEW = moves all extremities well
Skin WDI = Warm, dry, intact
HR regular, NSR s ectopies = Heart Rate regular, if the person is on monitoring, NSR = normal sinus rhythm s ectopies = (the s is a little s with a line above it - it means sans or without) ectopies, or beats originating other than where they should originate
LS CTA = Lung sounds are clear to auscultation
abd soft, flat, BS + x 4 quads = abdomen is soft, nontender, not distended, bowel sounds in all four quadrants of the abdomen
voiding s problems = peeing okay
0 c/o voiced, will monitor = No complaints, but I'll keep checking.
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Back to what nurses do