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.