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ASSESSMENT

A. Assessment Order

·         Inspection, Palpation, Percussion and Auscultation

·         For Abdominal assessment the order is: Inspection, Auscultation, Palpation, and Percussion.

 

B. Assessment Tools

  1. Glasgow Coma Scale

            The scale is a scoring system that determines ones level of consciousness, particularly during a traumatic brain injury. The scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. The total score is the sum of the         scores in three of the following categories:

Eye Opening Response

Spontaneous--open with blinking

4 points

Opens to verbal command, speech, or shout

3 points

Opens to pain, not applied to face

2 points

None

1 point

Verbal Response

Oriented

5 points

Confused conversation, but able to answer questions

4 points

Inappropriate responses, words discernible

3 points

Incomprehensible speech

2 points

None

1 point

Motor Response

Obeys commands for movement

6 points

Purposeful movement to painful stimulus

5 points

Withdraws from pain

4 points

Abnormal (spastic) flexion, decorticate posture

3 points

Extensor (rigid) response, decerebrate posture

2 points

None

1 point

 

 

  1. Mini Mental State Examination (MMSE) – Note: NCLEX will probably not ask the details of this test. This is just for your information.

            The Mini Mental State Examination (MMSE) is the most commonly used test for complaints of memory problems or when a diagnosis of dementia is being considered.

            The MMSE is a series of questions and tests, each of which scores points if answered correctly. If every answer is correct, a maximum score of 30 points is possible. People with Alzheimer's disease generally score 26 points or less. Note that this is not a test for Alzheimer's disease. The areas tested in MMSE are:    

·              Orientation – evaluated by asking the patient to say the date, day, month and year.

·              Memory - The first part of the memory test tests the ability to remember immediately three words. You will be given the names of three objects to remember - table, pad and pen, for example.

        

         Then, one is asked to immediately remember the three objects

 

·              Attention and Calculation  - One will be asked to count backwards. For example, start at 50 and count backwards by 5. One point is given for each correct subtraction, with a maximum of 5 points.

·              Recall - ability to remember the words that were mentioned earlier in the beginning.

·              Language, writing and drawing -  The final part of the test makes an assessment of spoken and written language, and the ability to write and copy.

     

        The person being tested is shown two everyday items - a hammer and a crayon, for example - and asked to name them. You score 1 point for each correct answer. You will then be asked to say aloud a tongue-twister              sentence such as 'Pass the peas please'.

                          Correctly repeating the sentence gains 1 point. The sentence is always the same, so is worth practicing once you have heard it the first time.

                          You will then be given a piece of paper, and asked to carry out a three-step process: ' Take this paper in your hand' ; 'Fold it in half' (1 point); 'Place it on this chair' (1 point). One point is gained for each correctly completed                     step. The instruction is given only once, but as with the tongue-twister, the task is  always the same.

                          A card is then shown with an instruction for a simple task - 'Clap your hands'. If you clap your hands you score 1 point.

                          The next stage of the test is to write a sentence on a piece of paper. The sentence needs to make sense. One point is scored for an acceptable sentence, and this is again something that can be practiced in advance. Examples of acceptable sentences include:

                                                'It's a lovely day today.'
                                                'My name is Ron.'

Finally, your ability to copy a design of two intersecting shapes is assessed. One point is awarded for correctly copying it. All angles on both figures must be present, and the figures must have one overlapping angle.

 

C. Pain

·         A patient in pain should experience an increase in respiration, blood pressure, and pulse

·         One can use, PQRST:  Palliative – determine what the patient did if anything to alleviate the pain;  Quality – how is the pain like (i.e. pressure like, stabbing like, pinch like);  Radiating – determine if the pain is radiating to other parts of   the body;  Severity – Use the scale of 1 – 10 with ten as the most painful to determine the severity of the pain;  Time – determine when the pain occurred and what the patient was doing at the time.

 

CONSENT

·         For surgical procedures, nurses should only provide doctors the consent forms and be a witness to the signature of the patient.

·         Physicians are responsible for explaining the procedure.

·         Nurses are not suppose to persuade patients to undergo a procedure.

 

INFECTION CONTROL

 

A. Hand washing

·         A proven way to prevent any type of infection.

·         Should at least be for 2 minutes long.

 

B. Infectious Organisms

1.  Botulism antitoxin

·              Made from horse serum. So, check for allergies to horses.

 

2.  Clostridium Difficile.

·              Symptoms include diarrhea with blood, mucus and white blood cells.

 

3.  Eschericia Coli (E.Coli)

·              Caused by uncooked or undercooked food.

 

4.  Histoplasmosis

·              Transmitted by birds.

 

5.  MRSA

·              Spread by direct contact from bloody fluids and patients skin.

·              Ask the patient to cover mouth and nose when coughing and sneezing.

·              Use gown, mask and gloves when giving care to an infected patient.

·              Patient may not have any symptoms.

·              Patient is put in isolation.

 

6.  Salmonella

·              Avoid reptiles

 

C.  Precautions

 

1.  Contact Precaution

 

·              Contact Precautions are intended to prevent transmission of infectious agents, including important microorganisms spread by direct or indirect contact with the patient or the patient’s environment.

·              Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission.

·              A single patient room is preferred for patients who require Contact Precautions. When a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). In multi-patient rooms, >3 feet spatial separation between beds is advised to reduce the opportunities for inadvertent sharing of items between the infected/colonized patient and other patients.

·              Healthcare personnel caring for patients on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient’s environment. Donning gown before room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, C. difficile, noroviruses and other intestinal tract pathogens; RSV).

 

2.  Droplet Precaution

 

·              Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Because these pathogens do not remain infectious over long distances in a healthcare facility, special air handling and ventilation are not required to prevent droplet transmission.

·              Infectious agents include B. pertussis, influenza virus, adenovirus, rhinovirus, N. meningitides, and group A streptococcus (for the first 24 hours of antimicrobial therapy).

·              A single patient room is preferred for patients who require Droplet Precautions. When a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). Spatial separation of patients by > 3 feet and drawing the curtain between patient beds is especially important for patients in multi-bed rooms with infections transmitted by the droplet route.

·              Healthcare personnel wear a mask (a respirator is not necessary) for close contact with infectious patient; the mask is generally donned upon room entry. Patients on Droplet Precautions who must be transported outside of the room should wear a mask if tolerated and follow Respiratory Hygiene/Cough Etiquette

 

3.  Airborne Precaution

 

·              Patients who have or may have an infectious disease that is spread by the airborne route must be placed on Airborne Precautions.

·              Requires a negative pressure room in addition to a private room. Negative pressure rooms are specially designed to prevent the flow of air from the room into the corridors and common areas where susceptible persons may be exposed. This is accomplished through fans and vents that direct the airflow outside of the building and/or through HEPA filters

·              Diseases requiring airborne precautions are rubeola virus [measles], varicella virus [chickenpox], Mycobacterium. tuberculosis, and possibly SARS-CoV)

·              Healthcare personnel caring for patients on Airborne Precautions wear a mask or respirator

·              In settings where Airborne Precautions cannot be implemented due to limited engineering resources (e.g., physician offices), masking the patient, placing the patient in a private room (e.g., office examination room) with the door closed, and providing N95 or higher level respirators or masks if respirators are not available. 

 

Phlebitis

·              Patient will complain of achiness or fullness before redness, heat and edema are seen or felt.

·              Apply heat to the site for 2 – 3 days to resolve phlebitis in the area.

 

 

LEGAL TERMS

1.   Fraud

·              False information.

2.   Libel

·              Writing down ones suspicions, thus, disclosing a privileged communication and leading to the lowering of opinion about a patient.

3.   Malpractice

·              Performing an act that causes harm to the patient.

4.   Negligence

·              Failure to perform a duty.

5.   Tort

·              When a wrongful act is committed on a patient or on his/her belongings.

 

RELIGION

1.  Islam

·              Person is prohibited from eating gelatin, pork and drinking alcohol

 

SAFETY

·         Bottles that are opened and not dated should be discarded.

·         JCAHO Guideline. Use arm band, medical record number and/or birth date as best identifiers when administering medication. Never use room numbers

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