The student nurse is performing a weber tuning fork test. what technique is most appropriate?
A head-to-toe assessment refers to a physical examination or health assessment, and it becomes one of the many important components of understanding a patient’s needs and problems. Show
Being a nurse means being a lot of things to a lot of people. But one of the basics of nursing is performing a head-to-toe assessment. We've put together a step-by-step guide to what happens in a nursing assessment and how nurses should understand the physical, emotional and mental aspects of someone’s body systems. Head-to-Toe Assessment Nursing ExpertsWe interviewed two healthcare experts to learn their best practices for conducting head-to-toe assessments. Terri Zucchero PhD, RN, FNP-BC is a nurse practitioner at Boston Health Care for the Homeless Program. Haynes Ferere, DNP, FNP-BC, MPH, serves as a clinical instructor at Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta. This article has also been reviewed by our panel of experienced registered nurses:
>> Click to See the Top Cheap and Fast Online RN to BSN Programs What is a Head-to-Toe Assessment?A head-to-toe assessment refers to a physical examination or health assessment, and it becomes one of the many important components of understanding a patient’s needs and problems. Head-To-Toe Assessment BasicsTypes of AssessmentsThere are several types of assessments that can be performed, says Zucchero.
Length of AssessmentFerere explains that the duration of the exam is directly in correlation to the patient’s overall health status. “Health patients with limited health histories may be completed in less than 30 minutes,” she says. “Many health practices have patients complete health history and pre-visit forms prior to presentation for a comprehensive visit. Review of these forms in advance can certainly reduce the required visit time.” How to Prepare for the Assessment“Like all clinical settings, standard precautions (formerly universal precautions) should always be practiced with each and every patient to protect both the nurse and patient,” states Zucchero. “The primary goal of standard precautions is to prevent the exchange of blood and body fluids and includes hand hygiene, use of personal protective equipment, and safe handling and cleaning of potentially contaminated equipment or surfaces.” Equipment ChecklistDepending on the type of assessment conducted, the nurse may need specific equipment, states Zucchero. Basic equipment includes:
Additional equipment for more comprehensive examinations would include,
Beginning An AssessmentWhen beginning an assessment, Zucchero says, “establishing a personal relationship of trust and respect between the patient and the nurse is vital.” She adds that is it important throughout an assessment to assess how the patient is doing, and make sure they are properly draped and comfortable. She continued, “in addition, it’s important that an assessment is conducted systematically and efficiently to minimize unnecessary touching of the patient.” “For new nursing graduates and nursing students, a head-to-toe assessment is driven by the needs of the patient, setting of the examination and the relationship with the examiner,” stated Angela Haynes. “This baseline examination determines knowledge about patient health needs, current health status and patient goals for personal health outcomes, including health promotion and wellness counseling,” she says. Starting an AssessmentBefore assessing any patient it is essential to perform hand hygiene either with hand sanitizer or soap and water. Then you will want to follow these basic steps:
What to look for During an AssessmentDifferentiating normal from abnormal is an important skill, Zucchero explains. Some examples of major abnormal findings are changes in normal respiratory rate that indicates respiratory distress, or a change in skin color such as pallor that may indicate anemia or jaundice that typically indicates liver problems. Generally, the human body is bilaterally symmetrical. When you are examining a patient, make note of any unusual asymmetry. If a patient is weaker on one side than another, or has a limited range of motion, or one side seems limper or otherwise different from the other side, there could be an underlying neurological or musculoskeletal issue. Building Rapport With the PatientThe nurse must always introduce themselves to the patient, verify they are with the correct patient, and explain what they will be doing, adds Zucchero. This is a good time to start with a review of paperwork and build a relationship before the physical portion of the exam is started, Ferere says. It is also the appropriate time to talk about the patient’s personal preferences about undressing for the exam, as well as lighting needs, the temperature of the room and any pain or areas of discomfort. “The patient may also prefer to have another person in the room for the exam for comfort. This should be allowed when possible. Policies are usually in place to support the presence of a witness for any invasive procedures,” she adds. Ferere adds that a cooperatively engaged patient visit may not be performed with the same sequence as a combative or confused patient. Engaging the patient early in the visit increases the likelihood that the patient will take more ownership of health status and ongoing health needs. Show Me Nursing Programs Pay Close Attention to Nonverbal Cues From the PatientThese cues can include grimacing with ambulation, grunting during movement or when making contact with a body system, Ferere says. “It may also be an avoidance of eye contact or reluctance to answer questions,” she adds. “The nurse must pay very careful attention to what the patient says and does not say during the visit. Oftentimes, nurses are acting as detectives during patient visits attempting to put together different findings, conversations and health histories.” Head-to-Toe Assessment SequenceFerere says the sequence is based on the examiner’s preference. Usually, it begins with the least invasive to most invasive allowing time for the patient to become more comfortable with the examiner. It also increases the likelihood that the examiner will not forget a system during the exam. “During an assessment, the first thing that should be noted is the patient’s overall appearance or general status,” Zucchero says. “This includes level of alertness, state of health/comfort/distress, and respiratory rate. This is done even prior to taking vital signs.” The Order of a Head-to-Toe Assessment
Show Me Nursing Programs Seek Out Help From Mentors And ColleaguesFerere adds that new nurses should trust the foundational knowledge obtained in nursing school and seek strong, supporting nursing mentors as resources in health care delivery settings. “Confidence in assessment continues to grow with every completed assessment. Nurses should not be afraid to ask for help when something does not seem right and rely on your instincts and training,” she says. FAQs:*This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease. Where is the tuning fork placed when the Weber test is performed?Weber test: Place the base of a struck tuning fork on the bridge of the forehead, nose, or teeth. In a normal test, there is no lateralization of sound. With unilateral conductive loss, sound lateralizes toward affected ear. With unilateral sensorineural loss, sound lateralizes to the normal or better-hearing side.
Where is the tuning fork placed when the Weber test is performed quizlet?During a Weber test, where should the tuning fork be placed? The Weber test is performed by striking the tuning fork and placing its stem in the midline of the client's skull or in the center of the forehead. In the Rinne test, the tuning fork is struck and placed on the mastoid process behind the ear.
In which area would the nurse place the tuning fork to perform the Weber test on a patient?The doctor strikes a tuning fork and places it on the middle of your head. You note where the sound is best heard: the left ear, the right ear, or both equally.
Which of the following tests uses a tuning fork?The Rinne test is conducted by placing a tuning fork on the mastoid bone and then adjacent to the outer ear. Air conduction uses the apparatus of the ear (pinna, ear canal, tympanic membrane, and ossicles) to amplify and direct the sound.
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