TODAY WE'RE GOING TO DO
A BASIC PHYSICAL ASSESSMENT.

THIS IS A PHYSICAL ASSESSMENT
THAT WE WANT YOU TO DO
ON ALL YOUR CLIENTS,

EVERY TIME YOU EVALUATE THEM,
EVERY TIME YOU CARE FOR A CLIENT
IN THE CLINICAL ENVIRONMENT.

THIS PARTICULAR PHYSICAL
ASSESSMENT IS A BASIC
PHYSICAL ASSESSMENT,

AND WE'RE GOING TO BUILD
ON COMPONENTS OF THAT
PHYSICAL ASSESSMENT,

AS YOU MAKE DISCOVERIES,
AS YOU FIND ABNORMALITIES
IN YOUR CLIENTS,

SO THAT YOU CAN BUILD ON THAT,
RECOGNIZE THE PARAMETERS
OF NORMAL AND ABNORMAL

AND MAKE CLINICAL DECISIONS
AS TO WHAT TO DO WITH
THOSE FINDINGS.

BUT WE'VE GOT TO HAVE A STARTING
PLACE AND A BUILDING PLACE

AND THAT'S WHAT WE ARE
GOING TO WORK ON TODAY.

THE VERY FIRST THING YOU WANT TO
DO IN A HEAD-TO-TOE ASSESSMENT,

AS YOU WOULD WITH ANY SKILL
THAT YOU'RE GOING TO PERFORM,

IS YOU SHOULD WANT TO CHECK THE
DOCTOR'S ORDERS AND YOU WANT TO
LOOK AT THE NURSING CARE PLAN.

THE DOCTOR'S ORDERS ARE
GOING TO TELL YOU WHAT YOUR
CLIENT'S DIAGNOSIS IS

AND WHAT KINDS OF EQUIPMENT
AND WHAT KINDS OF PROCEDURES

YOU CAN EXPECT TO HAPPEN
WITH THIS CLIENT.

SO, ON THE CLIENT
THAT I JUST REVIEWED,

I JUST FOUND OUT THAT THE
CLIENT HAD ABDOMINAL SURGERY

HAS A HISTORY OF COPD
AND HAS A HISTORY OF STROKE

WITH SOME RIGHT-SIDED WEAKNESS.

SO, THAT GIVES ME AN IDEA
OF SOME THINGS THAT
I WANT TO FOCUS ON.

MAKING SURE THAT I DO
A GOOD NEURO ASSESSMENT,

THAT I CHECK FOR THE IV,
THE OXYGEN SETTINGS,

NOTE THE DRESSINGS. DON'T FORGET
TO DO THAT ABDOMINAL ASSESSMENT.

LOOK AT THE FOLEY CATHETER
AND THOSE THINGS.

SO, WE'LL TALK ABOUT THOSE
AS WE PROGRESS.

ONCE I KNOW WHAT'S KIND OF
GOING ON WITH MY CLIENT,

THEN I WANT TO GATHER THE
APPROPRIATE EQUIPMENT.

AND FOR ME TODAY,
THE APPROPRIATE EQUIPMENT
IS GOING TO BE A STETHOSCOPE.

WHEN I TAKE VITAL SIGNS, IT'S
GOING TO BE THE THERMOMETER,
BLOOD PRESSURE CUFF.

THOSE KINDS OF EQUIPMENT.

AND THEN ALSO I HAVE IN MY
POCKET, MY PENLIGHT

SO THAT I CAN CHECK THE PUPILS
AND LOOK IN THE MOUTH

AND SOME DIFFERENT THINGS,
SO THAT I CAN CHECK MY CLIENT.

OKAY, I'VE WASHED MY HANDS,
AND THEN I'M GOING TO GO IN
AND IDENTIFY MY CLIENT.

FOR PURPOSES OF TEACHING TODAY,
I HAVE CONNIE WORKING
WITH ME HERE,

AND WE'RE GOING TO DO SOME
OF THE CONVERSATIONAL
PIECES WITH HER,

AND THE BREATHING AND THE
PUPILS, SO THAT YOU CAN
SEE SOME REACTION,

AND THEN WE'RE GOING TO
SWITCH OVER TO THE MANNEQUIN,

SO I CAN TALK ABOUT SOME OF THE
OTHER PHYSICAL ASSESSMENTS

AND EQUIPMENT THAT
WE WOULD EVALUATE.

I HAVE WASHED MY HANDS,
PROVIDED SOME PRIVACY,

FICTIONALLY SPEAKING HERE,

AND THEN I GOING TO IDENTIFY MY
CLIENT. GOOD MORNING.

HOW ARE YOU TODAY?
- OKAY.

- WHAT'S YOUR NAME?
- CONNIE.

- HOW ARE YOU FEELING
THIS MORNING?

- I'M DOING GOOD.

- DO YOU HAVE ANY PAIN?

- ER...JUST A LITTLE.

- WHAT DO YOU MEAN BY THAT?
CAN YOU DESCRIBE THAT?

- OH, WHEN I BREATHE
IT HURTS A LITTLE BIT.

- WHERE?

- UM...JUST...RIGHT IN THE
MIDDLE OF MY CHEST, RIGHT HERE.

- HOW LONG HAS IT BEEN HURTING?

- WELL, SINCE I CAME IN.

THAT'S, KIND OF, YOU KNOW,
WHY I CAME IN.

- UM...CAN YOU DESCRIBE
THE PAIN?

- IT'S JUST KIND OF TIGHT.

- DO YOU TAKE ANYTHING
FOR THE PAIN?

- NO, I HAVEN'T.

- AND YOU'VE BEEN HERE
FOR A WEEK AND IT'S
JUST BEEN THE SAME THING.

ON A SCALE OF ONE TO 10,
TELL ME THE WORST PAIN
YOU CAN EVER IMAGINE.

AND ONE BEING NO PAIN
OR ZERO BEING NO PAIN,

WHAT NUMBER WOULD YOU
GIVE THAT PAIN?

- ABOUT A TWO.
- OKAY.

ALRIGHT. WELL, WE'LL LISTEN
TO YOUR LUNGS

AND SEE IF THERE'S ANYTHING THAT
MAYBE IS CONTRIBUTING TO THAT,

AND THEN TALK TO THE DOCTOR
AND SEE WHAT WE CAN
DO ABOUT THE PAIN.

ANY OTHER PAIN? WHAT ABOUT YOUR
STOMACH AFTER THE SURGERY?

- UM...IT'S NOT...
IT'S BETTER NOW.

- SO PROBABLY ABOUT
A THREE.

IT WAS REALLY BAD
WHEN I FIRST STARTED.

- AND YOU'VE BEEN TAKING
PAIN MEDICINE FOR THAT?

- YES, I HAVE.
- THAT'S WORKING FOR YOU.

WHEN WAS THE LAST TIME
YOU TOOK THE MEDICINE?

- UH...ABOUT AN HOUR AGO.
- OH, GOOD.

THEN YOU'LL BE GOOD
TO MOVE AROUND A LITTLE BIT,
AND TAKE SOME DEEP BREATHS.

ARE YOU GETTING UP
AND WALKING TO THE BATHROOM?

- MM-HM.
- HOW'S THAT GOING?

- FINE.
- DO YOU GET SHORT OF BREATH,

WHEN YOU GET UP?
- A LITTLE, YEAH.

- ARE YOU COUGHING AT ALL?
- A LITTLE BIT.

- DO YOU GET ANYTHING UP
WHEN YOU COUGH?

- JUST A LITTLE BIT.
IT'S JUST...

A LITTLE BIT MORE
LIKE...KIND OF CLEAR COLORED.

- MORE IN THE MORNING
OR IN THE EVENING OR...

- MORE IN THE MORNING.

- THEN DOES IT STOP
LATER IN THE DAY?

- MM-HMM.

- ALRIGHT. WELL,
WHAT I'D LIKE TO DO IS JUST
DO AN ASSESSMENT OF YOU,

STARTING FROM YOUR EYES AND WORK
ALL THE WAY DOWN TO YOUR FEET.

AND KIND OF TALK TO YOU ALONG
THE WAY TO SEE HOW YOU'RE DOING
AND DO AN ASSESSMENT OF YOU.

ALRIGHT. SO, ONCE I'VE ASKED
THEM INTRODUCTORY QUESTIONS,

I KNOW SHE'S NOT IN MUCH PAIN,
I KINDA TALKED ABOUT HER
ACTIVITY A LITTLE BIT,

I'M GOING TO PIECE IT TOGETHER
AS I GO THROUGH HER ASSESSMENT.

WHEN WE TALK ABOUT DOING
A HEAD-TO-TOE ASSESSMENT,

WE WANT TO COVER
ALL THE SYSTEMS,

AND WE'VE GIVEN YOU A HAND-OUT
THAT HAS NEUROLOGICAL

MUSCULAR, SKELETAL
AND SKIN AND SO FORTH.

AND SOMETIMES YOU WANT TO
BE THINKING EACH INDIVIDUAL
SYSTEM AND THAT'S OKAY.

BUT WHAT WE WANT TO DO IS
BE SYSTEMATIC AND JUST COVER
THE BODY FROM HEAD TO TOE,

GATHER UP ALL OUR DATA
AND THEN WE'RE GOING TO
PUT ALL OF OUR DATA

IN THE APPROPRIATE SYSTEM WHEN
WE GO TO DOCUMENT AT THE END.

SO, WE'RE GOING TO
GATHER UP THE DATA,

THEN WE ARE GOING TO PUT IT INTO
ITS SYSTEM FOR DOCUMENTATION.

ALRIGHT.
WELL, THE FIRST THING I WOULD DO
IS CHECK HER VITAL SIGNS.

AND YOU WON'T BE ABLE TO SEE THE
VITAL SIGNS ON THE VIDEO CAMERA,

WE'VE ALREADY CHECKED UP
ON VITAL SIGNS.

BUT I'M GOING TO GO AHEAD
AND GET YOUR TEMPERATURE
AND SEE WHAT THE TEMPERATURE IS.

AND I'M GOING TO GET
YOUR PULSE AND RESPIRATIONS
HERE IN A MINUTE.

BUT THE FIRST THING I WANT TO DO
IS JUST CHECK YOUR EYES.

AND SO I'D LIKE TO LOOK
AT YOUR PUPILS AND SEE HOW
THEY'RE ARE REACTING TO LIGHT.

SO - STOP.

FOR ACCOMMODATION,
WHAT I WANT YOU TO DO, CONNIE,

IS WE'RE CHECKING
YOUR NEAR-SIGHTEDNESS
AND FAR-SIGHTEDNESS.

SO IF YOU WOULD LOOK
STRAIGHT AHEAD. OVER HERE,
THE CAMERAMAN'S HEAD.

AND YOUR EYES ARE SLIGHTLY
DILATED BECAUSE YOU'RE
PICKING UP FAR DISTANCE.

AND THEN I'M GOING TO
CHECK YOUR ACCOMMODATION

BY PUTTING MY FINGER
IN FRONT OF YOUR FACE

AND HAVE YOU FOCUS ON MY FINGER

AND I'M GOING TO BE LOOKING
TO SEE IF YOUR PUPILS CONSTRICT.

AND I JUST HAVE
HER COME UP HERE.

AND NOTICE THAT NOT ONLY DO HER
PUPILS CONSTRICT SLIGHTLY,

BUT THEY ALSO TURN IN
A LITTLE BIT AD SHE FOCUSES.

THESE ARE ALL NORMAL
RESPONSES OF THE EYE.

ALRIGHT. WE'VE CHECKED
CONNIE'S EYES AND NOTED THAT

CONNIE'S AWAKE,
CONNIE IS ALERT.

SHE'S FOLLOWING SIMPLE
COMMANDS AND SHE'S
TALKING SENSIBLY TO ME.

BUT WE ALSO WANT TO
PURPOSELY ASK SOME QUESTION.

I'VE ASKED HER HER NAME,
SO I KNOW SHE KNOWS WHO SHE IS.

CONNIE DO YOU KNOW
WHERE YOU ARE?

- I'M IN THE HOSPITAL.

- AND DO YOU KNOW
WHAT DAY IT IS?

- IT IS NOVEMBER 6TH.

- AND THE DAY OF THE WEEK?

- IT'S FRIDAY.

- SO, SHE'S ORIENTED TO PERSON,
PLACE AND TIME.

AWAKE. ALERT. ORIENTED.

PUPILS,
EQUAL AND RESPONSIVE LIGHT.

ROUND. EQUAL AND RESPONSIVE
TO LIGHT.

I'M ALSO BEGINNING TO NOTICE HER
SKIN AND THINGS ABOUT HER SKIN.

AND WE DON'T WANT TO MISS
THAT THROUGHOUT THE EXAM

BECAUSE SKIN IS
OUR LARGEST ORGAN,

AND SO WE'RE GOING TO BE NOTING
THAT FROM HEAD TO TOE.

AS I'M LOOKING AT HER FACE,
I'M SEEING THAT HER SKIN IS
INTACT, THAT THE COLOR IS EVEN.

I'M GOING TO TOUCH WITH THE BACK
OF MY HAND TO FEEL WARMTH
AND TEMPERATURE.

AND IT'S WITH THE PALMS OF MY
HAND THAT I'M GOING TO FEEL

MOISTURE, TEXTURE
AND THICKNESS OF SKIN.

BUT I'M NOTICING THAT HER SKIN
IS IN GOOD SHAPE.

I'M NOTICING THAT
SHE'S BREATHING EASILY.
THAT'S CALLED EUPNEA.

REGULAR, EVEN BREATHING.
THAT THERE'S NO FLARING
OF THE NOSTRILS.

SHE'S NOT GASPING FOR AIR.

AND THEN I'M MOVING ON
DOWN TO HER MOUTH.

I'M NOTICING FEATURES
OF HER FACE AND OF HER HEAD.

SO, HER LIPS ARE MOIST AND PINK.
THERE'S NO CRACKING.

BUT I'M GOING TO ASK YOU,
CONNIE, CAN YOU OPEN UP
YOUR MOUTH

AND LET ME LOOK INSIDE
AND SEE THE MUCUS MEMBRANES
OF YOUR MOUTH?

AND I'LL JUST TURN
MY PENLIGHT ON,

AND JUST LOOK TO SEE THAT
THERE'S NO LESIONS
OR SORES IN HER MOUTH.

I'M LOOKING AT HER TONGUE
TO MAKE SURE THAT

THERE'S NO PEARLS,
THAT IT'S NOT DRY,

THAT SHE HAS ALL OF HER TEETH,
THAT SHE'S ABLE TO CHEW

AND SHE'S ABLE TO SWALLOW
AND HANDLE FOOD.

ERM...A COUPLE OF QUESTIONS
I WANT TO ASK,
HOW IS YOUR APPETITE?

- UH...IT'S GOOD.

- YOU HAVE A SOFT DIET,
I NOTICED. ARE YOU DOING
OKAY WITH CHEWING THAT?

ANY PROBLEMS WITH DIGESTION?
ANY NAUSEA, VOMITING?

- NO.

- ANY DIFFICULTY SWALLOWING?
- UH...NO.

- I WAS READING IN YOUR CHART
THAT YOU HAD A STROKE

ABOUT A YEAR AGO AND THERE
WAS SOME RIGHT-SIDED WEAKNESS.

I'M NOT NOTICING
ANY IN YOUR FACE.

I'M SEEING YOU LIFT YOU EYEBROWS
AND THEY'RE LIFTING EASILY.

CAN YOU LIFT THEM MORE HIGH?
OKAY? THE EYEBROWS
OR EVEN YOUR SMILE?

AND YOUR CHEEKS ARE EVEN,
SO IT LOOKS LIKE ALL OF THAT
IS NICE AND BALANCED.

DO YOU NOTICE ANY WEAKNESS
IN GENERAL RIGHT NOW?

- NO.
- OKAY.

SO YOU SEEM TO HAVE RECOVERED
YOURSELF FROM THAT.
UM...ALRIGHT.

THE NEXT THING I WANT TO DO.
I'VE TALKED ABOUT APPETITE,
I'VE TALKED ABOUT SWALLOWING.

IF THAT'S WAS AN ISSUE, I COULD
PUT A TONGUE BLADE IN HER MOUTH

AND CHECK FOR THE GAG REFLEX
TO SEE IF THAT'S THERE,

BECAUSE YOU DON'T WANT PEOPLE
EATING IF THEY CAN'T SWALLOW,

IF THEY CAN'T GAG,
IF THEY'RE NOT ABLE
TO CONTROL THEIR FLUIDS.

SO THAT WOULD BE WORTH PERUSING
IT IF THAT WERE AN ISSUE,
BUT IT'S NOT.

SO SHE'S EATING FINE.
NO NAUSEA, VOMITING.
AND WE'RE GOING TO MOVE ON DOWN.

HER NECK LOOKS GOOD
AND BALANCED AND EVEN.

WE'RE ALWAYS LOOKING
FOR SYMMETRY.

I'M LOOKING HERE TO SEE
ON THE THYROID TO MAKE SURE

THAT THERE'S NO BULGES OR
ANYTHING THAT'S NOT SYMMETRICAL.

AND THEN I'M GOING TO MOVE
DOWN TO THE CHEST.

IT'S AT THE CHEST THAT
WE'RE GOING TO PICK UP
SOME MORE VITAL SIGNS.

WE'RE GOING TO LISTEN TO THE
HEART, LISTEN TO THE LUNGS

AND CHECK SOME OTHER THINGS.

ONE OF THE THINGS I'M GOING TO
DO IS COME RIGHT HERE
BELOW HER CLAVICLE

AND PINCH UP SOME SKIN,
AND WATCH IT SPRING BACK.

AND WHAT THAT IS
IT'S DOING THE SKIN TURGOR.

MOST PEOPLE, THEIR SKIN COMES UP
AND IT SPRINGS RIGHT BACK

AND THAT MEANS THEIR SKIN IS
MOIST, THEY'RE WELL HYDRATED.

IF THE SKIN STAYS
PEAKED OR TENSE,

ARE TWO OF THE TERMS
THAT YOU'LL READ IN THE BOOK,

THEN THAT MEANS THAT THEY MAY
HAVE SOME DEHYDRATION GOING ON.

THE MOST RECOMMENDED PLACE TO DO
IS RIGHT HERE BELOW THE CLAVICLE

BECAUSE MOST PEOPLE
ARE EQUALLY MOIST HERE.

PLACES THAT YOU WANT TO
AVOID ARE THE TOP OF THE HAND,

ESPECIALLY THE ON
THE GERIATRIC CLIENT,

BECAUSE IF YOU PINCH UP
THE SKIN, THEY HAVE OLD SKIN,

AND IT JUST STAYS TENTED,
AND IT HAS NOTHING TO DO
WITH HYDRATION,

JUST HAS TO DO WITH LOSS
OF ELASTICITY IN THEIR SKIN,
SO YOU WANT TO AVOID THAT.

SOME PEOPLE DO
WITH THE FOREARM TO SEE
IF IT WILL SPRING AS WELL,

BUT MOST OF THE TIME
THEY JUST RECOMMEND
THAT WE GO TO THE CLAVICLE.

WHEN I LOOK AT SOMEONE TO DO
AN ASSESSMENT OF THEIR
RESPIRATION AND THEIR CHEST,

I WANT TO LOOK AGAIN,
PHYSICALLY, AT SYMMETRY.

I'M LOOKING TO SEE IF THE
SHOULDERS ARE SYMMETRICAL,

LOOKING TO SEE THE THORAX
IS SYMMETRICAL,

AND I'M APPRECIATING
WHAT IS NORMAL.

A NORMAL CHEST,
THE TRANSVERSE CHEST,

THE DIAMETER OF THE CHEST
IS TWICE AS WIDE

AS WHAT WE CALL THE ANTERIOR,
POSTERIOR DIAMETER,

WHICH IS THE FRONT CHEST
TO THE BACK.

ANTERIOR. POSTERIOR.
WIDTH.

THIS WIDTH SHOULD BE HALF
THE WIDTH OF THE CHEST.

THAT'S WHAT A NORMAL
BODY LOOKS LIKE.

IF THE TRANSVERSE
WAS THE SAME AS THE FRONT,

THEN THEY'RE WHAT WE CALL
BARREL-CHESTED.

AND THAT MEANS THEY'VE PROBABLY
HAD COPD FOR A LONG TIME,

CHRONIC OBSTRUCTIVE PULMONARY
DISEASE. THEY'VE HAD AIR HUNGER.

AND THEIR CHEST HAS ACCOMMODATED
FROM THEM TRYING TO GET
MORE AIR, MORE AIR.

SO WE'RE LOOKING FOR THAT.
WE'RE LOOKING AT THE STERNUM

TO MAKE SURE IT'S NOT CONCAVE
OR PIGEON-CHESTED, STICKING OUT.

SO THINGS LOOK BALANCED
AND WELL HERE.

IT'S AT THIS POINT, WHAT I WANT
TO DO, I'VE LOOKED AT SYMMETRY -

ALSO YOU CAN NOTICE ON THE BACK
THAT THE SCAPULAR EVEN -

THAT THEY LOOK SYMMETRICAL.
AND IF YOU CLIENT CAN STAND UP.

AND WE'RE KIND OF SIMULATING
A HOSPITAL BED LYING DOWN HERE.

BUT YOU CAN LOOK AT THE BACK
TO LOOK FOR THINGS LIKE
SCOLIOSIS OR KYPHOSIS.

KYPHOSIS BEING A HUMP BACK,
SCOLIOSIS BEING A CURVATURE
OF THE BACK.

THOSE AREN'T ISSUES
IN HER HISTORY,

BUT THERE'RE ALWAYS
THINGS THAT WE'RE,

KIND OF, NOTING AND NOTICING
WITH OUR CLIENTS.

ALRIGHT. THE NEXT THING I
WANT TO DO IS I WANT TO
CHECK APICAL PULSE.

AND YOU'RE NOT GOING TO
BE ABLE TO HEAR,

BUT I DO WANT TO GO OVER
JUST THE LOCATION
OF THE APICAL PULSE.

AND THAT IS, WHEN WE'RE
LISTENING FOR APICAL PULSE,

WE WANT TO BE LISTENING
TO THE POINT OF MAXIMUM
IMPULSE, THE PMI.

THE POINT OF MAXIMUM IMPULSE
IS MIDCLAVICULAR LINE.

YOUR CLAVICLE BEING THIS PIECE
RIGHT HERE, AND IT'S THE
MIDDLE OF THE CLAVICLE.

AND THE FIFTH INTERCOSTAL SPACES
ARE POINT OF INTERSECTION.

SO, IF YOU START RIGHT HERE,
BELOW THE CLAVICLE.

ONE, TWO. AND YOU CAN COUNT
THE SPACES DOWN THE STERNUM.

JUST APPRECIATE THAT IT USUALLY
ENDS UP RIGHT ABOUT NIPPLE LINE,

WHERE THEY CONVERGE.

NOW, YOU JUST DON'T TAKE
SOMEONE'S PULSE ON THEIR NIPPLE.

ON A MALE, YOU TEND TO GO
RIGHT BELOW THE NIPPLE,

AND ON A FEMALE,
BECAUSE OF BREAST TISSUE,

YOU HAVE THE CHOICE
OF GOING RIGHT ABOVE

AND LAYING YOUR STETHOSCOPE
ON BREAST TISSUE ABOVE NIPPLE,

OR IF YOU'RE NOT HEARING WELL,
YOU CAN GO UNDERNEATH

THEIR CLOTHING AND LISTEN
BELOW THE BREAST.

BUT YOU'RE WANTING TO HEAR IS
THAT GOOD MITRAL VALVE CLOSURE.

IT'S THE MITRAL VALVE
THAT'S AT THE PMI.

THE FIFTH INTERCOSTAL SPACE,
MIDCLAVICULAR LINE.

AND SO THAT'S WHAT
WE WANT TO DO.

MY STETHOSCOPE IS BEEN CLEANED.
ALWAYS CLEAN THE DIAPHRAGM
BETWEEN USAGES OF YOUR CLIENTS.

SO I'M GOING TO SLIP IT DOWN
IN CLOTHING.

YOU DON'T HAVE TO STICK YOUR
HAND DOWN SOMEONE'S SHIRT.

AND THEN I'M JUST
GOING TO BE RIGHT HERE.

MIDCLAVICULAR,
ABOUT FIFTH INTERCOSTAL SPACE
AND LISTEN TO THE HEART.

WHEN YOU LISTEN TO THE HEART,
YOU WANT TO LISTEN
FOR A FULL MINUTE.

ALL OF OUR PULSES ARE
BASED ON A MINUTE COUNT,

AND YOU'RE NOT ONLY LISTENING
TO THE RATE TO SEE
HOW MAY BEATS PER MINUTE,

BUT YOU'RE LISTENING TO RHYTHM
AND THE STRENGTH.

IS IT REGULAR OR IRREGULAR?
AND THAT'S ALL WE
NEED TO KNOW RIGHT NOW.

WE'RE GOING TO FIGURE OUT WHAT
ALL OF THOSE DIFFERENT BEATS ARE
AS WE PROGRESS IN THE PROGRAM.

BUT RIGHT NOW,
JUST DETERMINE IF IT'S REGULAR,
IF THERE'S A RHYTHM?

IT'S LIKE MUSIC.
IT SHOULD BEAT STRAIGHT ALONG.

IT MAY SLOW A LITTLE
WITH RESPIRATION,
BUT THE BEAT STAYS THE SAME.

BOOM, BOOM-BOOM, BOOM-BOOM.

LUB, DUB. TWO BEATS,
TWO SOUNDS FOR ONE BEAT.

THE OPENING AND THE CLOSURE
OF THE VALVES.

YOUR LUB IS YOUR MITRAL
AND TRICUSPID VALVES CLOSING

AND YOUR DUB BEING THE AORTIC
AND THE PULMONARY VALVES
CLOSING TOGETHER.

THAT'S CALLED THE S1 AND THE S2

AND THAT'S WHAT
WE'RE LISTENING FOR.

SO BA-BUMP, ONE BEAT.
BA-BUMP, TWO.

BA-BUMP, THREE.
BA-BUMP, FOUR.

AND YOU'RE GOING TO COUNT
FOR A FULL MINUTE.

SOMETIMES YOU CAN LEAVE
YOUR STETHOSCOPE THERE

AND START LISTENING TO SOME
LUNG SOUNDS OR COUNT YOUR
RESPIRATORY RATE AS WELL.

BUT WE ARE GOING TO TALK ABOUT
RESPIRATION SEPARATELY.

ALRIGHT.
SO, YOU GET YOUR APICAL PULSE.

A NORMAL APICAL PULSE
BEING 60 TO 100.

IF IT'S LESS THAN THAT,
BRADYCARDIA, ANYTHING BELOW 60.

IF IT'S HIGHER THAN THAT,
TACHYCARDIA, THAT'S OVER 100.

YOU WANT TO REPORT THOSE
TO YOUR FACULTY OR TO THE NURSE

THAT'S TAKING CARE
OF THE PATIENT FOR THE DAY
THAT'S RESPONSIBLE,

BECAUSE THOSE ARE ABNORMAL
BREATHINGS AND MAY NEED
TO HAVE SOME INTERVENTION.

ALRIGHT. CONNIE, I'D LIKE
TO LISTEN TO YOUR LUNGS

AND WHAT I WANT TO DO IS LISTEN
TO THE FRONT SIDE OF YOUR CHEST
AND THE BACK SIDE OF YOUR CHEST.

AND WHAT I NEED YOU TO DO
IS TAKE A GOOD DEEP BREATH
IN AND OUT OF YOUR MOUTH.

IF YOU BREATHE THROUGH
YOUR NOSE, I PICK UP
REFERRED SOUNDS

THROUGH THE...SINUSES
AND SO WE DON'T WANT THAT,

WE JUST WANT TO HEAR
THE AIR PASSING.

I'M GOING TO LISTEN TO THE FRONT
ON ABOUT 4 TO 6 PLACES
AND THEN ON THE BACK.

THEN IF YOU GET LIGHT-HEADED,
LET ME KNOW,

'CAUSE ALL THAT DEEP BREATHING
SOMETIMES IS LIKE, "WOO!"

OKAY.

MAKE SURE THAT YOU PUT YOUR
STETHOSCOPE TO SKIN,
WHEN YOU CAN,

THAT WAY YOU DON'T PICK UP
THE ARTIFACT OF CLOTHING
AND YOU GET A NICE CLEAR SOUND.

SO, WE'RE GOING TO START UP HERE
ON THE UPPER CHEST.

WE ALWAYS START FROM TOP
TO BOTTOM, SIDE TO SIDE,

COMPARING WHAT YOU HEAR
ON THE RIGHT SIDE TO WHAT
YOU HEAR ON THE LEFT SIDE.

ALRIGHT. IF YOU COULD TAKE
A GOOD DEEP BREATH FOR ME.

MAKE SURE YOU LISTEN
TO THE FULL INSPIRATION
AND THE FULL EXPIRATION.

ANOTHER ONE.

WATCH YOU CLIENT AND SEE
HOW YOUR CLIENT'S DOING.

THERE'S NO NEED TO STARE
AT THE STETHOSCOPE,

BECAUSE THE STETHOSCOPE DOESN'T
DO ANYTHING WHEN YOU LOOK AT IT.

BUT LOOK AT YOUR CLIENT TO SEE
HOW YOUR CLIENT IS DOING.

FOR ONE, IF THEY'RE BREATHING
THROUGH THEIR MOUTH.

IF YOU SEE THAT THEY'RE
GETTING LIGHT-HEADED.

IF YOU'RE NOTICING ANY DISMAY,
DISCOMFORT WITH BREATHING.

YOU CAN COME UP THE SIDE
AND THEN CHECK THE SIDE LUNGS.

ANOTHER GOOD BREATH.

AGAIN, COMPARING SIDE TO SIDE.

GOOD.

IF YOU TURN THEN I CAN
SEE WHAT I CAN DO HERE.

THEN, YOU CAN DO THE SAME THING.

NOW, CONNIE, CAN YOU CROSS
YOUR ARMS OVER LIKE THAT?

WHAT HAPPENS IF THEY CROSS
THEIR ARMS IS THE SCAPULAR
IS SPREAD APART.

BECAUSE YOU DON'T WANT TO BE
LISTENING ON TOP OF BONES,

YOU WANT TO BE LISTENING
TO LUNG SPACES.

SO, THAT JUST GIVES YOU A LITTLE
MORE SPREAD AND WE ARE GOING TO
LISTEN UP AT THE TOP.

THIS SIDE OVER HERE.
HMM...ONE MORE.

AND THEN COME DOWN.

YOU'RE LISTENING TO THE
MIDDLE OF THE LUNG,

BUT REALLY WHEN YOU'RE ON
THE BACKSIDE OF THE CHEST,
IT'S ALL THE LUNG BASE.

AND YOU'RE LISTENING TO,
HOPEFULLY, THE SICULAR SOUNDS.

AND THEN TRY TO GET
TO THE BASE OF THE LUNGS.

YOU REALLY JUST NEED TO BE
LISTENING TO ONE BREATH.

IF YOU'RE LISTENING TO 3 OR 4
BREATHS IN EACH SECTION

AND THEN IN EACH SECTION YOUR
CLIENT'S GOING TO HYPERVENTILATE
AND THEY'RE GOING TO PASS OUT.

SO, I KNOW IT'S HARD
IN THE BEGINNING.

IF YOU HEAR AN UNUSUAL SOUND,
THEN YOU CAN STOP
AND WORK THE PARAMETERS

AND SEE WHERE THE SOUND
STOPS AND BEGINS.

BUT AS LONG AS IT'S A NICE,
CLEAR SOUND, MOVE ON.

AND SO THAT YOUR CLIENT
DOESN'T HYPERVENTILATE.

ALRIGHT.
THANK YOU VERY MUCH, CONNIE.

THE REST WE'RE GOING TO DO
ON THE MANNEQUIN, BUT WE
NEEDED SOME INPUT ON THOSE.

ALRIGHT. WE'RE GOING TO KINDA
SWITCH GEARS OVER HERE,

JUST SO THAT WE CAN LOOK
AT SOME MORE EQUIPMENT
AND MAKE SOME MORE ASSESSMENTS.

I'M NOTICING THAT MY CLIENT HERE
HAS OXYGEN ON IN THE NOSE AREA.

AND, YOU KNOW, BY THE WAY,
YOU HAVE COPD,

HOW DO YOU DO BREATHING
AT THAT LEVEL?

SOMETIMES PEOPLE THINK IT'S EASY
TO BREATHE WITH THEIR HEAD UP.

SO THE HIGHER THE HEAD,
THE EASIER FOR RESPIRATION,

SO YOU MAY WANT TO MAKE AN
ADJUSTMENT WITH YOUR CLIENT
SO THAT BREATHING IS EASIER.

I'M NOTICING THAT THEY
HAVE NASAL PRONGS.

YOU'LL SEE THE ABBREVIATION
NP ON THE CHARTS OR NC,

WHICH IS NASAL CANNULA.
AND THAT'S HOW THE AIR
IS GETTING TO THEM.

THE LITTLE PRONGS, THE LITTLE
FORKS SHOULD FACE INTO THE NOSE,
NOT BACKWARDS, THE OTHER WAY,

'CAUSE THAT SHOOT THE AIR
OUT THE TOP OF THE NOSE.

SO, THE PRONGS ARE IN.

AND I'M CHECKING THE NOSE TO
MAKE SURE THERE'S NO IRRITATION
AND RUBBING FROM THE NOSE.

SOMETIMES THEY GET SORE
FROM BEING UP THERE.

ALSO, YOU WANT TO
CHECK BEHIND THE EARS

AND MAKE SURE THAT THERE'S
NO SKIN BREAKDOWN AS WELL.

MY MANNEQUIN DOESN'T
HAVE VERY GOOD EARS.

I'M GOING TO COME OVER HERE
AND LOOK AT THE OXYGEN

AND CHECK THE LITER FLOW.

THE DOCTOR ORDERED ONE LITER
PER MINUTE PER NASAL PRONGS,

AND SO I WANT TO COME UP HERE
AND SEE THAT MY OXYGEN

IS BEING DELIVERED AT THE
LITER FLOW THAT'S BEEN ORDERED.

AND IT CERTAINLY IS.
THE LITTLE BALL.

AND I'M JUST GOING TO RAISE
IT HERE. I DON'T KNOW IF
THE CAMERA CAN PICK THAT UP.

BUT IT'S WHEREVER THE BALL IS
LANDING ON THESE NUMBERS HERE

THAT TELL YOU YOUR LITER FLOW.

SO, MY BALL'S RIGHT THERE
AT ONE.
LITER FLOW IS SET RIGHT.

I'VE ALREADY TALKED TO MY CLIENT
AND THEY ARE NOT COMPLAINING
OF ANY DIFFICULTY BREATHING.

WE'LL ASSESS THAT AS EUPNEA,
OF NO NASAL FLARING.

ALSO, WHEN I LOOKED AT THE CHEST
I DIDN'T NOTICE

ANY LARGE GASPING-TYPE
BREATHS OR RETRACTIONS,

WHICH IS THE PULLING IN OF SOFT
TISSUE BETWEEN THE RIB CAGES.

RIB CAGE, OR UNDERNEATH THE RIB,
OR BELOW THE STERNUM,

WHICH WILL BE
INTERCOSTAL RETRACTIONS
BETWEEN THE RIB SPACES.

SUBCOSTAL RETRACTIONS.

SOMETIMES PEOPLE, ESPECIALLY
KIDS, WHEN THEY HAVE ASTHMA AND
THEY ARE HAVING DIFFICULTY,

THEY SUCK IN THE AIR SO HEAVILY
THAT THEIR STERNUM DIPS IN,

OR THEY'RE DIPPING IN AT THE
DIAPHRAGM AREA, SUBSTERNAL.

SO, THOSE ARE THINGS THAT WE
WOULD BE LOOKING FOR AND OUR
CLIENT LOOKS PRETTY COMFORTABLE.

AS WELL AS CHECKING THE HEART
RATE, THE APICAL HEART, WE WANT
TO GET A RESPIRATORY RATE.

AND SOMETIMES IT'S JUST
AS EASY AS, YOU KNOW, YOU'VE
DONE VITAL SIGNS ALREADY,

TO CHECK A RADIO PULSE, AND SO
THEY THINK THAT YOU'RE GETTING

YOUR RADIO PULSE AND YOU'RE
WATCHING THE RESPIRATORY RATE.

YOU WANT TO AT LEAST COUNT THE
RESPIRATIONS FOR 30 SECONDS

AND SOMETIMES A MINUTE,
IF IT'S YOUR REGULAR.

YOU DO WANT TO GO AHEAD
AND GET A RADIO PULSE AS WELL,

BECAUSE WE WANT TO MAKE SURE
THAT THE RADIO PULSE AND THE
APICAL PULSE ARE SIMILAR.

THEY SHOULD BE WITHIN A COUPLE
OF BEATS OF EACH OTHER.

ESPECIALLY BECAUSE YOU'RE NOT
TAKING THEM AT THE SAME TIME.

IF THERE'S A LARGER GAP
THAN THAT, THEY MAYBE HAVE
WHAT'S CALLED A PULSE DEFICIT.

IN OTHER WORDS, WHAT'S HAPPENING
AT THE HEART, ISN'T HAPPENING
AT THE EXTREMITIES,

AND WE HAVE A DEFICIT OF
CIRCULATION HERE AND WE WOULD
WANT TO PERUSE THAT.

YOU TALK ABOUT THAT
IN VITAL SIGNS.

BUT GO AHEAD AND GET YOUR
RADIO PULSE. AGAIN, IT'S
RATE, RHYTHM AND STRENGTH.

IT'S NOT JUST COUNTING A NUMBER,
BUT DO WE HAVE A REGULAR RHYTHM

AND IS IT A STRONG, WEAK,
THREADY OR BOUNDING TYPE PULSE.

WHAT DO YOU HAVE GOING ON?

OKAY. I'M NOTICING HERE,
AS LONG AS WE ARE

IN THE CARDIOVASCULAR SYSTEM,
THAT THE CLIENT DOES HAVE AN IV.

AND AN IV IS INTRAVENOUS FLUID.

WE WANT TO MAKE SURE
THAT THE FLUID HANGING

IS WHAT THE DOCTOR HAS ORDERED,
AND WE HAVE SODIUM CHLORIDE.

WE WANT TO MAKE SURE THAT
IT'S GOING IN THE RATE
THAT THE DOCTOR HAS ORDERED.

OUR IV RIGHT NOW
IS A GRAVITY DRIP,

WHEREAS MOST OF THE TIME
IN THE HOSPITAL YOU'RE GOING TO
SEE IT GOING IN VIA A PUMP.

SO, MAKE SURE THAT
THE PUMP RATE IS WHAT...

OR WHATEVER REGULATING DEVICES,
THAT THE RATE IS SET AT
WHAT THE DOCTOR ORDERED.

SO WE'VE GOT OUR SOLUTION,
WE GOT OUR RATE

AND THEN YOU WANT TO COME DOWN
HERE AND YOU WANT TO LOOK
AT THE SIGHT OF THE IV.

YOU WANT TO KNOW WHERE IT'S AT,
SO THIS IS IN THE RIGHT FOREARM.

YOU WANT TO MAKE SOME
OBSERVATION THAT, THE SITE
DOESN'T HAVE ANY REDNESS.

REDNESS WOULD BE AN
INDICATION OF PHLEBITIS,
INFECTION OF THE VEIN.

SO, WE DON'T HAVE ANY
REDNESS OR STREAKING.

WE DON'T HAVE
ANY SWELLING, EDEMA,

WHICH MEANS THAT THERE WAS
SWELLING OR HARDNESS HERE
THAT IT HAD INFILTRATED.

THAT MAYBE THE FLUID
INSTEAD OF GOING IN THE VEIN
IS LEAKING INTO TISSUE.

AND IT'S NOT LEAKING
OR THERE'S NO TENDERNESS.

ALWAYS KINDA PALPATE THE SITE
TO MAKE SURE THAT
IT DOESN'T HURT THEM.

BECAUSE INFILTRATION IS
UNCOMFORTABLE AS TENDER

AND YOU'LL SEE THAT
PHRASEOLOGY A LOT.

I MEANT TO MENTION IN THE
BEGINNING OF OUR ASSESSMENT THAT

AS WE'RE DOING OUR ASSESSMENT,
WE'RE ACTUALLY UTILIZING
3 OF THE 4 MODES OF ASSESSMENT.

THE FIRST BEING INSPECTION.
WE ALWAYS LOOK AT THINGS FIRST.

NOTICE THAT WE LOOK AT
THE SKIN FIRST. WE LOOK
AND ASSESS THE TRUNK FIRST.

WE LOOKED AT THE MOUTH FIRST
BEFORE WE TOUCH
OR BEFORE WE LISTEN.

BECAUSE YOU WANT TO MAKE SURE
THAT YOUR PURPOSE TO LOOK
AT THE RIGHT THING,

OR IF YOU NEED GLOVES,
YOU'RE PUTTING GLOVES ON
BEFORE YOU JUST PLOUGH IN,

OR THAT YOU ARE DOING
THE RIGHT SEQUENCE OF ORDER.

ESPECIALLY WHEN GET DOWN HERE
TO THE ABDOMEN THAT WE'RE
DOING THE RIGHT THINGS.

SO FAR WHAT WE'VE DONE IS MOSTLY
INSPECT AND AUSCULTATE.

WE'RE JUST GOING TO DO
A LITTLE MORE PALPATION HERE
BECAUSE I WANT TO FEEL THE SKIN.

I GOING TO LIFT THIS CLIENT UP
A LITTLE BIT HERE.

WE WANT TO FEEL THE SKIN.
AGAIN, FOR MOISTURE,
TEXTURE, THICKNESS.

I'M LOOKING FOR BURSES,
LESION, CUTS.

I'M LOOKING AT
BONEY PROMINENCES.

PARTICULARLY AT THIS POINT,
THE ELBOWS, TO SEE IF WHILE
THEY'RE IN BED

IF THERE ARE HAVING PROBLEMS
WITH SHEARING.

YOU KNOW, THEY KIND OF SCOOP
THEMSELVES UP WITH THEIR ELBOWS,
SINCE THEY CAN RAISE THEIR HEAD,

AND MAKE SURE THAT THERE'S
NO SKIN BREAK AS WELL.

AND COMPARE ONE SIDE
TO THE OTHER,

TEMPERATURE AND THEN MOISTURE,
TEXTURE, THICKNESS.

HAIR DISTRIBUTION.
THINGS THAT WOULD INDICATE THAT
EVERYTHING IS LOOKING NORMAL.

ALRIGHT.

I'M GOING TO MOVE ON DOWN HERE
TO THE ABDOMEN.

I'VE ALREADY TALKED TO
MY CLIENT ABOUT APPETITE

AND THINGS RELATED TO THE
GASTROINTESTINAL SYSTEM.

BUT I ALSO WANT TO LOOK HERE
AT THE ABDOMEN.

THE FIRST THING I WANT TO DO
IS INSPECT AND IT'S EASIER

TO INSPECT YOUR CLIENT IF THEY
ARE A LITTLE BIT FLATTER.

BUT YOU DO WANT THEIR KNEES UP
A LITTLE, 'CAUSE THAT TAKES
SOME OF THE PRESSURE OFF.

HOW'S THAT,
WITH YOUR BREATHING?

AND I JUST WANT TO LOOK AT YOU
FOR A FEW MINUTES, SO IF YOU CAN
TOLERATE THAT IT WOULD BE GREAT.

I'M GOING TO PUT HIM FLAT,
AND MY FIRST THING I
WANT TO DO IS INSPECT.

I'M INSPECTING THE ABDOMEN
AND I'M LOOKING FOR CONTOUR.

CONTOUR BEING THE SHAPE
OF THE ABDOMEN.

IT'S EITHER GOING TO BE CONCAVE,
SINKING IN,

FLAT, ROUNDED, OBESE.

WE MIGHT CALL IT DISTENDED.

SOMETIMES YOU CAN TELL
THAT THERE'S A FIRMNESS
ABOUT IT WITHOUT TOUGHING.

BUT THE FIRST THING WE NEED TO
DO IS LOOK BEFORE WE TOUCH,
AND THEN AUSCULTATE.

IF WE TOUCH BEFORE WE AUSCULTATE
WE STIMULATE FALSE BOWEL SOUNDS.

AND WE DON'T WANT TO DO THAT.
WE WANT TO CARE OF WHAT

THEIR BOWEL SOUNDS ARE
AT THIS RUSTIC POINT.

SO, I'M LOOKING FIRST.
I'M NOTICING, I CAN'T MISS.

THERE'S A LARGE DRESSING
HERE ON THE ABDOMEN.

I WANT TO NOTE THE DRESSING
AND I WANT TO NOTE THAT THIS
DRESSING IS DRY AND INTACT.

ALL THE EDGES ARE TAPED. THERE'S
NO DRAINAGE COMING THROUGH.

I'VE TALKED TO THE CLIENT
ABOUT PAIN. THAT LOOKS FINE.

I'M NOT SEE ANY OTHER
SCARS OR LESIONS.

THE UMBILICUS IS MID LINE,
THERE'S NO DRAINAGE.

AND I THINK EVERYTHING
IS IN PRETTY GOOD SHAPE.

WHAT I WANT TO DO AT THIS POINT
IS I WANT TO TAKE MY STETHOSCOPE

AND I WANT TO LISTEN
TO BOWEL SOUNDS.

I LIKE TO START AT THE
RIGHT LOWER QUADRANT.

QUADRANTS BEING, IF YOU CUT THE
STOMACH IN QUARTERS, HAVING THE
UMBILICUS BE THE MID LINE POINT.

IN THE CENTER HERE,
PERPENDICULAR,

IS OUR IMAGINARY CUT-THROUGH
PLACE AND THEN ACROSS.

IN THIS LOWER QUADRANT,
IF WE LISTEN HERE, THIS IS WHERE
THE ILEOCECAL VALVE IS,

AND THAT'S WHERE WE WILL
MOST LIKELY HEAR BOWEL SOUNDS.

AND THEN WE CAN JUST KINDA
FOLLOW THE COLON ALONG

IF YOU GO IN A CLOCKWISE FASHION
TO HEAR BOWEL SOUNDS.

SO, WE ARE GOING TO PUT
ARE STETHOSCOPE DOWN,

AND AS SOON AS YOU HEAR BOWEL
SOUNDS, YOU CAN MOVE ON.

WE'RE GOING TO COME UP HERE TO
THE SECOND QUADRANT, LISTEN.

WE'RE LISTENING FOR GURGLING,
CRACKLING NOISES.

PARASITOSIS, MOVING THE FLUID
THROUGH THE BODY.

AS SOON AS YOU HEAR A NOISE,
YOU CAN MOVE ON, AND YOU LISTEN
TO ALL FOUR QUADRANTS.

IF YOU DON'T HEAR
ANY BOWEL SOUNDS,

YOU HAVE TO KEEP YOUR
STETHOSCOPE THERE
FOR ABOUT A MINUTE.

A MINUTE AND 15 SECONDS.

IF YOU DON'T HEAR ANYTHING
FOR ONE FULL MINUTE THEN

YOU MOVE TO THE NEXT QUADRANT
AND LISTEN FOR ONE FULL MINUTE.

YOU'RE NOT GOING TO SAY THAT
BOWEL SOUNDS ARE ABSENT,

UNTIL YOU'VE LISTENED TO A TOTAL
OF 5 MINUTES TO THE ABDOMEN.

AND IF YOU HEAR NOTHING
IN 5 MINUTES,

THERE ARE NO BOWEL SOUNDS AND
THEN YOU CAN DOCUMENT AS SUCH.

WE'RE ALSO GOING TO PUT THE
CRITERIA OF HYPOACTIVE,

NORMAL, HYPERACTIVE
OR BORBORYGMUS BOWEL SOUNDS.

THE BORBORYGMUS IS THAT WHEN
YOU'RE STAVING AND YOUR STOMACH
SAYS, "GR-R-R-R-R."

HYPOACTIVE BOWEL SOUNDS
ARE LESS 5 TINKLES.

5 LITTLE SOUNDS THAT YOU
MIGHT HEAR IN THAT MINUTE
THAT YOU'RE THERE.

A NORMAL BOWEL HAS ANYWHERE
FROM 5 TO 30 OR 35 SOUNDS
IN THE PERIOD OF A MINUTE.

SO BOWELS CAN BE REALLY ACTIVE.
IT'S THAT BOWEL LOUD, LOUD SOUND
THAT'S JUST NONSTOP.

THAT IS YOU HYPERACTIVE
BOWEL SOUND.

ALRIGHT. ONCE YOU'VE AUSCULTATED
ABDOMEN AND YOU KNOW THAT THE
BOWELS ARE ACTIVE,

YOU MIGHT ASK YOUR CLIENT AT
THIS POINT, HAVE YOU HAD A BOWEL
MOVEMENT RECENTLY?

AS ESPECIALLY ARE
POST-SURGICAL CLIENT.
ARE YOU EVEN PASSING GAS?

IS SOMETHING HAPPENING? IS
SOMETHING MOVING OUT THERE?

SO FLATUS, GAS, BOWEL MOVEMENT.

"WHEN WAS YOUR LAST BOWEL
MOVEMENT?"

TODAY? YESTERDAY?
THREE DAYS AGO?

AND CAN YOU DESCRIBE IT? SO YOU
KINDA KNOW WHERE THEY'RE AT.

WHAT'S YOUR NORMAL BOWEL
REGIMENT. DO YOU USUALLY HAVE
A BOWEL MOVEMENT EVERY DAY?

WE MIGHT NOT EXPECT
A BOWEL MOVEMENT THAT FIRST
OR SECOND DAY AFTER SURGERY,

BECAUSE THEY'VE BEEN IN PO
FOR A FEW DAYS AND SO FORTH.

BUT WE WANT TO KEEP TABS ON THAT
SO WE DON'T GET BEHIND ON THAT

AND WE'RE GIVING THEM
APPROPRIATE SIMULATION HERE.

ONCE YOU'VE CHECKED ON THE
BOWELS AND THE GAS AND SO FORTH,

IT'S TIME TO PALPATE
THE ABDOMEN.

WHEN YOU PALPATE THE ABDOMEN
YOU'RE GOING TO USE THE PADS
OF YOUR FINGERS

AND YOU'RE JUST GOING TO DO A
SOFT PALPATION, MAYBE A HALF OF
AN INCH DOWN, A CENTIMETER.

AND YOU'RE GOING TO TAKE
3 FINGERS AND KINDA
ROTATE THE FINGERS,

AND YOU JUST PRESSING TO SEE
IF YOU FEEL ANY ABNORMALITIES,

IF THERE'S ANY LUMPS,
IF THEY HAVE TENDERNESS
WHEN YOU PALPATE.

SOMETIMES YOU CAN FEEL STOOL,
SOMETIMES YOU CAN FEEL
GAS MOVING,

BUT WHAT'S GOING ON
WITH THAT ABDOMEN.

IS THERE DISTENSION?
ARE THERE NODULES?

ARE THERE ANYTHING THAT
YOU'RE PICKING UP AS
YOU'RE CHECKING THIS ABDOMEN?

BE GENTLE, ESPECIALLY IF
THERE HAVE ABDOMINAL PAIN.

WE'RE CHECKING HERE FOR
SOFTNESS VERSUS FIRMNESS,
RIGIDITY, WHERE ARE THEY AT?

IF YOU KNOW THAT THERE
HAVE PAIN IN THEIR ABDOMEN,

YOU WANT TO START AT THE PLACE
THAT DOESN'T HURT FIRST

BEFORE YOU PALPATE
THE MOST TENDER PLACE.

BECAUSE IF IT'S MOST TENDER,
THEN THEY GET RIGID AND TENSE

AND YOU'RE UNABLE TO PALPATE
THE REST OF THE ABDOMEN.

SO, NICE, GENTLE, KIND OF
A ROTATING WITH 3 FINGERS

AND GO ALL THE WAY AROUND
CHECKING THE ABDOMEN THOSE
THINGS I MENTIONED.

ALRIGHT, WE DO WANT TO
MOVE ON DOWN. AGAIN,
STAYING SYSTEMATIC HERE.

AND WE'RE GOING TO CHECK,
ONE, THAT OUR CLIENT
HAS A FOLEY CATHETER

AND WE'RE NOTING HERE
THAT THIS IS MALE GENITALIA.

YOU'RE GOING TO NOTE IF
THERE IS ANY DISCHARGE,
ANY HYGIENE ISSUES.

IS THE CATHETER INTACT.
ANY ABNORMALITIES ON THE MALE.

ARE THEY CIRCUMCISED
OR UNCIRCUMCISED,
WHAT'S GOING ON DOWN THERE?

SO JUST TAKE NOTE OF GENITALIA.

ALSO, NOTICE THE FOLEY CATHETER
COMING DOWN.

WE WANT TO MAKE SURE THAT
WE HAVE A GOOD LINE THAT'S
NOT KINKED OR CRIMPED OFF.

YOU WANT THE FOLEY CATHETER
TO COME UP OVER THE LEG

VERSUS UNDER THE LEG BECAUSE
THAT KEEPS THE FLOW PATENT.

ON A MALE, ACTUALLY, YOU COULD
BRING THE FOLEY CATHETER

AND TAPE IT ON TO THE ABDOMEN
IF IT'S MORE COMFORTABLE

OR YOU CAN BRING IT UP HERE
AND TAPE IT ONTO THE THIGH.

ONE OF MY PREFERENCES IS TO MAKE
SURE THAT THIS IS SECURED

ON THE UPPER PART OF THE LEG
AS SUPPOSED TO BETWEEN THE LEGS,

SO THAT WHEN THEY PUT THEIR LEGS
TOGETHER YOU DON'T HAVE

THE PRESSURE OF THE FOLEY
CATHETER BETWEEN THEIR LEGS.

THE PLACE WE LIKE TO SECURE THE
FOLEY CATHETER IS RIGHT HERE
AT THE BIFURCATION,

WHERE YOU HAVE THE BALLOON
PIECE AND THEN YOU HAVE
THE FOLEY CATHETER.

IF YOU TAPE IT UP HERE,
ON THE FOLEY CATHETER PORTION

OF THE CATHETER ITSELF,
FOR THE GRAVITY DRAINAGE,

IT'S A SOFT RUBBER AND IT WILL
COMPRESS IT, AND CONSTRICT IT,

SO THAT THE FLOW SOMETIMES
BECOMES NON-PATENT.

WHEREAS IF YOU TAPE DOWN HERE
ON THE DRAINAGE BAG HALF
OF THE FOLEY CATHETER,

IT'S SO HEAVY THAT IT PULLS
THE CATHETER OFF.
IT WON'T STAY TAPED.

SO THIS SEEMS TO BE THE
BEST PLACE TO SECURE
THE FOLEY CATHETER.

YOU NEED TO STABILIZE
THE FOLEY CATHETER

BECAUSE IF IT'S NOT STABILIZED
IT FLOPS BACK AND FORTH

AND IT CAN CAUSE IRRITATION AT
THE MEATUS AND THAT CAN CAUSE

MIGRATION OF BACTERIA WHICH CAN
LEAD TO URINARY TRACT INFECTION.

SO IT NEEDS TO BE STABILIZED.

ON THE MALE, THEY HAVE
6 TO 8 INCHES OF URETHRA,
OF URINARY TRACT HERE,

AND SO THEY'RE NOT GOING TO GET
AS MUCH MIGRATION AS MAYBE

THE FEMALE WOULD WHO ONLY HAS
2-INCH TRACT OF URETHRA,

BUT NEVERTHELESS YOU DON'T
WANT TO HAVE THAT TRAUMA

THAT COMES FROM THIS FLOPPING
BACK AND FORTH,

YOU WANT TO BE AS SENSITIVE
TO THAT AS POSSIBLE.

NOTICE I'M NOT TOUCHING
THIS, BECAUSE I DON'T HAVE
GLOVES ON RIGHT NOW.

IF I'M GOING TO TOUCH THIS,
RETAPE THIS, HANDLE THIS,
I NEED TO PUT GLOVES ON.

THEY'RE NOT WEARING
UNDERWEAR HERE, SO THERE'S
GOING TO BE DRAINAGE.

THIS BAG THEY USE FOR A WEEK
AND URINE SPLASHES AND GETS
ALL OVER THE PLACE.

LET ME TURN THIS HERE
SO THAT YOU CAN SEE.

MY BAG IS TAPED HERE ONTO THE
SIDE OF THE BED, NOT TO A SIDE
RAIL OR SOMETHING THAT MOVES,

AND WE EMPTY THAT FREQUENTLY
SO THE POTENTIAL OF BODY FLUIDS

IS A REALITY WITH THE FOLEY
CATHETER, SO MAKE SURE
THAT YOU ALWAYS USE A GLOVE.

YOU DON'T NECESSARY HAVE
TO PUT 2 GLOVES ON,

YOU CAN TAKE ONE AND JUST
USE IT TO HANDLE AND MOVE,

BUT MAKE SURE THAT YOU ALWAYS
USE GLOVES TO STABILIZE.

ALRIGHT, WHEN YOU'RE LOOKING
AT THE FOLEY CATHETER,

YOU WANT TO COME DOWN HERE
AND YOU WANT TO ASSESS
THE URINE.

AND YOU'RE LOOKING FOR THE
AMOUNT, YOU'RE LOOKING
FOR THE QUALITY.

IN OTHER WORDS, IS IT CLEARER?
IS THERE SEDIMENT?

IS IT CLOUDY?
IS IT MUCUSY?

AND ALSO YOU ARE LOOKING
TO SEE WHAT COLOR IT IS.

IS IT YELLOW?
IS IT BRIGHT YELLOW?

IS IT AMBER?
IS IT RUSTY COLORED?

IS IT...

WHAT IS IT?
LIGHT YELLOW.

GIVE AN INDICATION OF WHAT THE
URINE LOOKS LIKE AND THE VOLUME.

A NORMAL KIDNEY SHOULD
PUT OUT MORE THAN
30 MILLILITERS PER HOUR,

SO WE'RE JUST KEEPING
AN EYE ON THAT.

ARE THE KIDNEYS FUNCTIONING?
ARE THEIR KIDNEYS FUNCTIONING
AS THEY SHOULD

AND ARE WE GETTING AN
APPROPRIATE VOLUME
FROM THE BLADDER.

ALRIGHT,
I'M GOING TO MOVE ON DOWN HERE.

AND I'M GOING TO NOTICE
THE SKIN AGAIN.

I'M NOTICING THE MOISTURE,
TEXTURED, THICKNESS.
THAT IT'S INTACT.

I'M ALSO NOTICING JOINTS. THAT
I'M NOT SEEING ANY DEFORMITIES.

THAT THEY'RE MOVING JOINTS,
THAT THEY'RE MOVING IN BED
AND SO FORTH.

I'M LOOKING AT THE FEET.

AND BEFORE I TOUCH THE FEET,
I DID WANT TO COME UP HERE

AND I REMEMBER ON MY CLIENT THAT
I DO WANT TO...AT THE HANDS.

I WANT TO HAVE 'EM
GRIP MY FINGERS.

AND I KNOW I'M KINDA TURNING
MY BACK TO THE CAMERA.

BUT I WANT TO GIVE THE CLIENT
MY FINGERS TO GRIP,
TO SEE HOW THEIR STRENGTH IS.

I WANT TO COMPARE BOTH SIDES,
ESPECIALLY THIS CLIENT
THAT HAS A HISTORY OF A STROKE.

I GIVE HIM 2 FINGERS TO GRIP AND
I'M FEELING HOW STRONG IS IT.

YOU MIGHT WANT TO GIVE
DIRECTIONS THAT THEY DON'T HAVE
TO GRIP IT THEIR VERY HARDEST,

JUST A NICE, FIRM GRIP
TO COMPARE STRENGTH.

THEN I WANT THEM TO PUT THEIR
HANDS UP LIKE THIS AND I WANT
THEM TO PUSH AGAINST ME,

SO I CAN FEEL THAT THEY
HAVE STRENGTH, PASSIVE
AND RESISTIVE STRENGTH.

OR YOU CAN PUT YOUR HANDS HERE
AND YOU CAN HAVE 'EM
PULL AGAINST YOU,

SO THAT YOU CAN FEEL THEY'RE
RESISTIVE AS WELL AS
THEY'RE PUSHING STRENGTH.

ALRIGHT.

I'M GOING TO...ALSO,
I'M JUST THINKING,

IT'S HARD WHEN THEY DON'T HAVE
ANY REAL BLOOD CIRCULATION,

YOU DON'T ALWAYS GET THE Qs,

BUT AT THE HANDS YOU
WANT TO CHECK FOR
THEIR CAPILLARY REFILL.

AND YOU WANT TO COMPARE
BOTH SIDES TO SEE HOW
THEIR CIRCULATION IS.

AND WHAT I MEAN BY THAT,
AND YOU CAN SEE REALLY WELL
ON MY OWN FINGERS,

IS THAT OUR CIRCULATION
GOES TO OUR FINGERTIPS

AND IF WE SQUEEZE DOWN IT
BLANCHES THE CIRCULATION

AND WHEN WE RELEASE,
THE REFILL TIME SHOULD BE BRISK,
IT SHOULD BE ONE TO 2 SECONDS.

NORMAL REFILL IS LESS
THAN 2 SECONDS.

AND THAT'S ALL YOU DO,
IS JUST THAT PINCHING DOWN
TO SEE HOW FAST IT FILLS.

AND SO WE WOULD SAY
OF MY FINGERS,

RAPID CAPILLARY REFILL,
CAPILLARY REFILL
LESS THAN 2 SECONDS.

OKAY. WE'RE FEELING THE LEGS,
WE'RE CHECKING TEMPERATURE

TO MAKE SURE BOTH LEGS
ARE EQUALLY WARM OR COOL.
WE'RE ALSO CHECKING FOR EDEMA.

AND TYPICALLY, EDEMA
STARTS DOWN AT THE FEET.
EDEMA BEING SWELLING.

AND WHAT I DO IS
I COME DOWN HERE FIRST
AND I COME UP ON THE TOE.

I COME BETWEEN THE GREAT TOE AND
I COME BETWEEN THE SECOND TOE

AND I FIND THE TOP OF THE BONE
AND I CHECK FOR A PULSE.

AND WHILE I'M CHECKING
FOR MY PEDAL PULSE,
DORSALIS PEDIS,

I'M KIND OF PRESSING TO SEE IF
THERE'S ANY SWELLING DOWN HERE.

ONCE I FIND THE PULSE,
COMPARING TO THE RIGHT SIDE
TO THE LEFT SIDE,

THEN I GIVE A GENTLE SQUEEZE
DOWN HERE AND SEE IF
I CAN PICK UP ANY EDEMA.

IF I PICK UP ANY SWELLING,
ANY FULLNESS OR THEY
COMPLAIN OF DISCOMFORT,

THEN I'M ALSO GOING TO COME UP
HERE TO THE ANKLES, AND I'M
GOING TO COME UP HERE GENTLE,

COS IT'S UNCOMFORTABLE
WHEN YOU'RE SQUEEZING
AND THEY'RE HAVING SWELLING,

AND SEE HOW FAR THE SWELLING
COMES UP ONTO THEIR EXTREMITIES.

IF THERE'S PITTING, IF WHEN YOU
PUSH IN ON THE SWELLING AND YOUR
FINGER PRINT STAYS IN THE SKIN,

THEN YOU'RE GOING TO HAVE
TO START DETERMINING
HOW MUCH PITTING THIS IS.

WE GRADE PITTING ON SCALE OF
1 PLUS TO 4 PLUS, AND IT'S
A LITTLE BIT SUBJECTIVE.

EVEN WHEN YOU READ IN YOUR BOOKS
THEY TALK ABOUT 2 DIFFERENT
WAYS THAT PEOPLE GRADE.

1 PLUS BEING A SENSE OF FULLNESS
AND 4 PLUS BEING A DEEP PIT THAT
LAST MORE THAN 3 TO 4 SECONDS.

SOME PEOPLE GRADE THE PITTING
BASED ON HOW LONG THE
INDENTATION STAYS IN THEIR SKIN,

OTHERS JUST LOOK AT THE
DEPTH THAT IT GOES TO,
THE CENTIMETERS.

IF IT'S ONE CENTIMETER,
IF IT'S 1 PLUS,

IF IT'S 4 CENTIMETERS DOWN,
IT'S 4 PLUS.

SO A LITTLE SUBJECTIVE,
BUT INDICATING THAT WE HAVE

A LITTLE BIT OF EDEMA VERSUS
WE HAVE A LOT OF THE EDEMA.

WHEN I LOOK AT THE TOES,
I ALSO WANT TO BE LOOKING TO SEE
IF THERE'S ANY BREAKDOWN.

I WANT TO BE LOOKING AT THE
NAILS TO SEE IF THEY'RE THICK

OR THIN OR WHAT KIND
OF HYGIENE THERE IS.

YOU CAN ALSO DO A QUICK
CAPILLARY REFILL CHECK AS WELL.

I WANT TO HAVE MY CLIENT,
AT THIS POINT,
GO AHEAD AND TURN OVER

BECAUSE YOU WANT TO CHECK
THE BACKSIDE
AND SEE WHAT'S GOING ON.

AND I WANT TO BE LOOKING HERE
AT THE SKIN, AT THE BACK,

AT THE BACK OF THE HEAD TO SEE
IF THERE'S ANY SKIN BREAKDOWN.

I WANT TO BE LOOKING
AT THE SCAPULAR,

MAKING SURE HERE AT
THE ILIAC CREST, AT THE SACRUM.

THAT THERE'S NO BREAKDOWN
ON THE HEELS ESPECIALLY.

YOU WANT TO BE LOOKING AT ANY
BONY PROMINENCE TO MAKE SURE
THAT EVERYTHING IS INTACT.

ALL THE WHILE, I'M ALSO TALKING
TO THE CLIENT AND SEEING HOW
COOPERATIVE THEY ARE,

NOTICING THEIR MOOD,
THEIR AFFECT...

ALONG WITH THE PAIN AND JUST
GETTING AN IN-GENERAL FEELING

OF HOW THEY'RE DOING
PSYCHO-SOCIALLY, AS WELL AS
PHYSICALLY AND MENTALLY.

TURN AROUND HERE.

YEAH. I'M GOING TO GO AHEAD
AND LOWER THE BED HERE.

OOPS! DO YOU WANT YOUR HEAD UP
FOR BREATHING?

AND THAT OXYGEN'S
NOT STAYING ON. VERY GOOD.

PUT THE BED DOWN
IN A LOWER POSITION.

IS THERE ANYTHING THAT
YOU'D LIKE ME TO CHECK ON

OR ANYTHING ELSE THAT
YOU THINK I NEED TO KNOW?

I TALKED A LITTLE ABOUT
THE MEDICATIONS YOU'RE ON.

I WOULD WANT TO FOLLOW UP
AND MAKE SURE THAT I KNOW
WHAT MEDS THEY'RE ON,

SO THAT I CAN APPRECIATE
IF THE MEDICATION IS CAUSING

A BLOOD PRESSURE OR UPHOLDS TO
BE WITHIN A CERTAIN PARAMETER.

WHEN THEIR LAST PAIN MEDS WERE?
THIS IS A GOOD TIME
TO DO TEACHING.

WE TALKED A LITTLE BIT
ABOUT THEIR COUGHING.

WE TALKED ABOUT DEEP BREATHING
AND ACTIVITY LEVELS.

DO YOU HAVE ANY DIZZINESS,
HAVE YOU NOTICED,

WHEN YOU GET UP AND DOWN,
WHEN YOU GO TO THE BATHROOM?

AND THEY SAY NO. BUT THESE
ARE THE TEACHING POINTS

AND ASSESSMENT POINTS
THAT WE WANT TO LOOK AT.

ALRIGHT.

AFTER I'M DONE ASSESSING
THE CLIENT I WANTED TO SAY,

I'VE CHECKED EVERYTHING,
LOOKS PRETTY GOOD.

AGAIN, I'VE ASKED IF
THERE'S ANYTHING THAT
THEY WANT ME TO KNOW.

IT'S AT THIS POINT THAT I WANT
TO CLEAN MY STETHOSCOPE.

YOU WANT TO MAKE SURE THAT WHEN
YOU'RE DONE WITH EACH CLIENT

THAT YOU CLEAN THE DIAPHRAGM AND
THE BELL OF YOUR STETHOSCOPE.

YOU DON'T HAVE TO CLEAN THE
EARS, THEY'RE YOUR EARS, UNLESS
SOMEONE ELSE IS GOING TO USE IT.

I'M GOING TO WASH MY HANDS
AND THEN I'M GOING TO
DOCUMENT MY FINDINGS.

I WANT TO TALK A LITTLE BIT
ABOUT THE FINDINGS,

BECAUSE IT'S AT THIS POINT,
EVERYTHING WE DID

FROM HEAD TO TOE, WE NEED TO
NOW PUT IN THE CORRECT SYSTEM.

SO WHEN WE TALK ABOUT
THE NEURO SYSTEM

AND I'M THINKING ABOUT WHAT I
ASSESSED AND WHAT I FOUND,

I WANT TO SAY THAT MY CLIENT WAS
ALERT AND ORIENTED TIMES THREE,

THAT THE PUPILS WERE EQUAL
AND REACTIVE TO LIGHT
WITH ACCOMMODATION

GRIPS WERE EQUAL AND STRONG.

AND NOW I'M THINKING I DIDN'T
DO THEIR FEET AND I SHOULD
GO BACK DO THEIR FEET,

BECAUSE I NEED THE PLANTAR
REFLECTION AND THE DORSAL
REFLECTION OF THE FEET.

SO I'M STILL IN THE ROOM
AND I'M HAVING THAT THOUGHT,

AND SO WHAT YOU WOULD TO DO
IS SIMPLY GO DOWN HERE SAY,

"YOU KNOW WHAT,
I FORGOT TO CHECK YOUR FEET."

COME DOWN AND HAVE 'EM PUSH
AGAINST YOUR HAND AND PULL.

THE PUSHING AND THEN PUSH...
YOU'RE PUSHING AGAINST THEM
AND THEY'RE PUSHING DOWN,

THIS IS PLANTAR REFLECTION.

AND THEN WITH THEM PULLING UP,
WHILE YOU'RE PULLING DOWN,
AGAIN THAT RESISTIVE TENSION,

IS THE PLANTAR
REFLECTION...DORSAL REFLECTION.

DORSAL GOES THEM UP,
PLANTAR IS THEM DOWN
AND THEN PLANT THEIR FEET IN.

ALRIGHT.

THERE YOU GO.
WASH YOUR HANDS ONE MORE TIME.

NEURO.
THOSE WERE ARE NEURO THINGS.

THEY WERE ALERT AND ORIENTED,
THEY'RE CONSCIOUS. WE DIDN'T
HAVE ANY DEFICITS THERE.

RESPIRATORY.
WE WANT TO RESPOND TO THE RATE.

THE RATE BEING,
WE'RE JUST GOING TO SAY 16.

THE LUNGS WERE CLEAR
BILATERALLY.

WE DON'T HAVE TO SAY
EVERY SINGLE LOBE,

WE JUST HAVE TO SAY THAT BOTH
SIDES ARE CLEAR TO AUSCULTATION.

IF THERE'S NOT. IF YOU HAD
ANOTHER FINDING LIKE
WHEEZES, RAILS, BRONCHI,

THEN YOU WOULD SAY
WHERE YOU FOUND THEM.

RIGHT UPPER LOBE,
RIGHT LOWER LOBE.

LEFT UPPER LOBE,
LEFT MIDDLE LOBE, WHERE ON
THE ANATOMY OR ALL LOBES.

"THROUGHOUT" IS A TERM THAT
YOU HEAR PERIODICALLY
IN DOCUMENTATION.

YOU'RE GOING TO TALK ABOUT
AND YOU CAN USE THE TERM EUPNEA.

THE RESPIRATIONS WERE EASY.
THEY WERE REGULAR.

WE WANT TO KNOW NOT ONLY THE
RATE, BUT THE DEPTH AND THE
QUALITY OF THE RESPIRATION.

IF THEY'RE STRUGGLING, YOU WOULD
USE WORDS LIKE DYSPNEA.

APNEA, NO RESPIRATION.
THAT'S LIFE THREATENING. THIS IS
GOING TO BE A SHORT FORM.

YOU JUST WANT A
RESPONSE TO THOSE.

ALRIGHT. SO RESPIRATIONS. RATE
THE QUANTITY AND THE QUALITY
AND WHAT YOUR AUSCULTATION WAS.

THE CARDIOVASCULAR.
THE APICAL RATE.

SO OUR APICAL RATE,
WE'LL JUST SAY IT WAS 80,

REGULAR, STRONG VERSUS WEAK
VERSUS IRREGULAR.

YOU ALSO WANT TO TALK ABOUT
CIRCULATIONS SO THE CAPILLARY
REFILL WOULD GO INTO THIS.

THE CAPILLARY REFILL WAS BRISK,
LESS THAN 2 SECONDS.

AND YOU WANT TO PUT YOUR
IV INTO THIS SECTION

BECAUSE THE IV IS
ALSO INTO THE VEIN.
THIS IS A VASCULAR ASSESSMENT.

SO, ON THE IV,
WE HAVE 0.9% SODIUM CHLORIDE,

INFUSING AT 100CC PER HOUR
PER THE RIGHT ARM,

WITH NO SIGNS AND SYMPTOMS...
WITH NOT SIGN OF REDNESS,

SWELLING OR EDEMA, EITHER OF
THOSE WORDS OR TENDERNESS.

SO WE'VE ADDRESSED THOSE THINGS
THAT WE'VE FOUND HERE.

ALRIGHT.
RESPIRATORY.

I'M LOOKING AT MY CLIENT
AND REALIZING I FORGOT
TO MENTION THE O2.

OXYGEN WOULD GO INTO
THE RESPIRATORY SECTION,

SO YOU CAN COME BACK HERE
AND ADD THIS.

OXYGEN, 2 LITERS PER MINUTE
PER NASAL PRONGS
OR NASAL CANNULA.

THE GI. THE GI IS EVERYTHING
THAT IS GASTRO AND INTESTINAL.

SO IT'S FROM OUR MOUTH.
WE NOTICED THAT OUR MUCUS
MEMBRANES WERE PINK AND MOIST.

THAT THE TEETH WE THERE,
THAT THE TONGUE WAS MOIST,
THAT THERE WERE NO LESIONS.

NO COMPLAINS OF NAUSEA
OR VOMITING.

THIS PATIENT'S STATES
MY APPETITE IS GOOD.

WHAT KIND OF DIET THEY'RE ON.
SOFT DIET.

IT'S ARE ABDOMINAL ASSESSMENT
THAT GET PUT INTO THIS
PARTICULAR SECTION.

SO ABDOMEN WAS SOFT, FLAT.

THE DRESSING CAN GO EITHER
WITH THE GI OR CAN GO
WITH THE INTEGUMENTARY

BECAUSE YOU'RE IN THAT SYSTEM.
BUT LET'S JUST STAY WITH THE
ABDOMEN HERE FOR A SECOND.

ABDOMEN WAS SOFT, FLAT.
BOWEL SOUNDS ACTIVE.

NO TENDERNESS ON PALPATION.

EXACTLY WHAT YOU SAW AND WHAT
YOU DID WHILE YOU WERE THERE.

THE GU SYSTEM.
WE HAD MALE.

GENITAILIA. NO DISCHARGE,
NO REDNESS.

FOLEY CATHETER,
PATENT WITH CLEAR, YELLOW URINE.

YOU CAN EVEN SAY THE VOLUME.
100CC IN THE LAST TWO HOURS
OR SO FORTH.

YOU CAN SAY GREATER
THAN 30CC PER HOUR.

WE TYPICALLY DON'T EMPTY
THE FOLEY CATHETER,
EXCEPT PER SHIFT,

SO EVERY 8 HOURS THAT WOULD
GET EMPTIED AND THEN WE'D SEE
THE TOTAL VOLUME THERE.

BUT YOU AN BE EYE-BALLING
TO SEE HOW MUCH IS IN THERE

AND IT SHOULD BE ACCUMULATING,
SO FORTH.

ALRIGHT. SO, URINARY TRACT.

BACK UP TO GASTROINTESTINAL
AS WELL, YOU CAN ADD UP
HERE BOWEL MOVEMENTS.

IF THEY'RE HAVING ANY FLATUS.
IF THEY'VE HAD A BOWEL MOVEMENT
AND DESCRIBE THE BOWEL MOVEMENT.

QUANTITY, HOW MUCH?
QUALITY AND COLORS.

SO, WAS IT FORMED?
WAS IT RUNNING?

WAS IT PUDDING-LIKE?
AND SO FORTH.

MUSCULAR SKELETAL. OUR CLIENT
MOVED ALL EXTREMITIES WELL.

OUR CLIENT DIDN'T HAVE ANY
ABNORMALITIES AT THE JOINTS.
NO REDNESS, NO TENDERNESS.

AT THE JOINTS,
ABLE TO AMBULATE INDEPENDENTLY.

I LIKE TO CREATE A PICTURE THAT
TELLS ME WHAT THE CLIENT CAN DO.

DO THEY NEED ASSIST GETTING OUT
OF BED? ARE THEY STRONG ENOUGH
TO WALK ON BOTH LEGS? SO FORTH.

SO WE ALREADY TALKED ABOUT
THEIR PUSHES AND GRIPS
FOR EQUAL AND STRONGER.

OUR CLIENT IS ALSO INDEPENDENT
AND UP TO THE BATHROOM
AND NO DEFORMITIES NOTED.

THE INTEGUMENTARY.

OUR SKIN WAS PINK,
DRY AND INTACT.

WE NOTICED THE COLOR.
THE TEMPERATURE WAS WARM.

SO IT'S AT THIS POINT
YOU WOULD BE REFERRING TO THOSE.

WE HAD NO SKIN BREAKDOWN AREAS,
EXCEPT FOR OUR DRESSING.

WE'RE NOT GOING TO TALK
ABOUT THE WOUND BECAUSE
WE HAVEN'T SEEN THE WOUND,

WE'VE ONLY SEEN THE DRESSING.
SO YOU CAN JUST SAY 4 BY 4
ON MID-ABDOMEN,

SECURED WITH PAPER TAPE,
CLEAN, DRY AND INTACT.

THERE WAS NO DRAINAGE ON IT
AND IT'S STILL ON THE ABDOMEN.

PATIENT TEACHING.
THERE'S MUCH TO BE SAID
ABOUT PATIENT TEACHING.

WHAT YOU DID AND WHAT
YOU CAN DO.

AND THAT IS THE PULMONARY
HYGIENE, THE TURNING,

THE COUGHING, THE DEEP
BREATHING, ACTIVITY LEVEL,

THE DIET THAT YOU THOUGHT
ABOUT...THE DRESSING,

THE PAIN MEDICATIONS,
THE ACTIVITY RELATED
TO BOWEL MOVEMENT.

ALL OF THAT CAN BE INCLUDED
IN THIS PATIENT TEACHING.

SO WHAT YOU DID DO
AND WHAT YOU PLAN TO DO.

AND THEN THAT'S HOW
YOU CAN PUT ALL OF
YOUR INFORMATION TOGETHER.

I'VE JUST DISCOVERED THAT
REALLY IT'S EASIER IF,

WHAT YOU DO IS YOU JUST START
WITH YOUR CLIENT FROM YOUR HEAD,

LOOK AT EVERYTHING THAT'S THERE,
GATHER UP YOUR INFORMATION

AND THEN PUT YOUR INFORMATION
INTO ITS SYSTEM,

RATHER THAN TRY TO DO NEURO,
WHICH WOULD BE EYES,
SQUEEZE AND FEET

AND THEN GO BACK AND FORTH
AFTER YOU'VE TOUCHED FEET,

'CAUSE YOU DON'T WANT TO
TOUCH AROUND THE FACE.

SO, JUST START FROM HEAD,
WORK DOWN TO THE FEET

AND THEN PUT ALL OF YOUR
INFORMATION TOGETHER
ON THIS HAND-OUT.

ALRIGHT. THAT'S IT.

WE'LL BE PURSUING MORE LATER.
HOPE THAT HELPS.

ALRIGHT. THE FIRST THING WE WANT
TO DO IS LOOK AT THE PUPILS

OF HER EYES AND WE'RE GOING TO
BE CHECKING PUPILLARY RESPONSE.

SO, BEFORE I PUT THE LIGHT
IN HER EYES TO SEE IF THERE'S
A REACTION TO LIGHT,

I'M GOING TO MEASURE
HER RESTING PUPIL.

AND I'M LOOKING AT MY PARAMETER,

MY MEASURING DEVICE, TO SEE THAT
THIS IS ABOUT 3 MILLIMETER.

WE CAN ACTUALLY SEE IT BETTER
IF I DO IT THIS WAY.

BUT IT'S 3 MILLIMETERS.
AND I'M LOOKING TO SEE WHAT
HER PUPILS ARE HERE AT REST.

IT'S KIND OF A DIM LIGHT
IN THE ROOM.

NORMAL PUPILS ARE
3 TO 5 MILLIMETERS.

SO, WE LOOK AT THE RESTING PUPIL
AND THEN WE LOOK AT THE PUPIL
AS IT REACTS TO LIGHT.

BUT LET ME BACK UP
JUST A MINUTE.

THE FIRST THING I'M ALSO DOING
IS I'M LOOKING TO SEE
THAT THE PUPILS,

THE SIZE OF THE PUPILS
AND THEIR CONFIGURATION.

SO BOTH OF HER PUPILS ARE ROUND
AND BOTH OF THEM ARE EQUAL.

ALWAYS COMPARE ONE EYE
TO THE OTHER.

BOTH PUPILS ARE
ABOUT 3 MILLIMETERS.

THEN WHAT I WANT TO DO IS
I WANT TO SHINE A LIGHT INTO
THEM AND SEE HOW THEY RESPOND.

SO YOU WANT TO
TURN YOUR PENLIGHT ON

AND THEN COME IN FROM THE SIDE
AND LOOK AT THE RESPONSE.

THIS PUPIL REACTED BRISKLY.
SO, PUPILS EQUAL AND REACTIVE
TO LIGHT.

AND THEN THERE WAS
A CONSENSUAL RESPONSE.

AS I SHINE THE LIGHT
INTO THIS PUPIL,
THIS ONE RESPONDED AS WELL.

THIS ONE SHRINKS AND THAT ONE
SHRINKS IN RESPONSE,
A CONSENSUAL RESPONSE.

WHATEVER YOU DO TO ONE SIDE OF
THE BODY, YOU WANT TO DO TO THE
OTHER AND COMPARE THE RESPONSE.

SO I'M GOING TO COME IN HERE
AGAIN FROM THE SIDE

AND NOTICE THAT IT SHRUNK
AGAIN FROM 3 TO 2

AND THAT THERE WAS RESPONSE
HERE IN HER OTHER EYE.

SO, PUPILS EQUAL
AND REACTIVE TO LIGHT,

WHICH IS WHAT WE CALL PERLL,
P-E-R-L-L.

AND THERE'S ONE OTHER THING
THAT WE WANT TO DO,

AND I'M GOING TO HAVE CONNIE
BACK UP JUST A LITTLE BIT

AND HOPE YOU CAN PICK THIS UP
IN THE CAMERA,

BUT THIS IS CALLED
THE ACCOMMODATION.