By Burns, Suzanne M.; Chulay, Marianne
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Extra resources for AACN
Auscultation of bowel sounds should be done in all four quadrants in a clockwise order, noting the frequency and presence or absence of sounds. Bowel sounds are usually rated as absent, hypoactive, normal, or hyperactive. Before noting absent bowel sounds, a quadrant should be listened to for at least 60 to 90 seconds. Characteristics and frequency of the sounds are noted. After listening for the presence of normal sounds, determine if any adventitious bowel sounds such as friction rubs, bruits, or hums are present.
The family, as well as the patient, experiences the grieving process, which includes the phases of denial, shock, anger, bargaining, depression, and acceptance. 117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission. Inspect the skin for overall integrity, color, temperature, and turgor. Note the presence of rashes, striae, discoloration, scars, or lesions. For any abrasions, lesions, pressure ulcers, or wounds, note the size, depth, and presence or absence of drainage.
Note the amount and color of drainage and whether an air leak is present. Verify whether the chest tube drainage system is under water seal or connected to suction. COMPREHENSIVE ADMISSION ASSESSMENT 13 caffeine, nicotine, and narcotics, as well as akathisia from phenothiazines, may mimic anxiety. Additional etiologic variables associated with anxiety include pain, sleep loss, delirium, hypoxia, ventilator synchronization or weaning, fear of death, loss of control, high-technology equipment, and a dehumanizing setting.