Focus Assemssment Flashcards
What is a focused assessment?
When a nurse performs a specific assessment of a body system
When is a focused assessment done?
When a pt has a complaint relating to a certain body system or has a certain illness
What kind of focused assessment can be done that are in the NII’s?
Respiratory
Cardiac
Abdominal
Neuro
Peripheral Neuro vascular
What should we worry about going into a pt room?
LOC and ABCs (airway, breathing and circulation)
What is differrent about a focused assessment?
Collect data about a problem that has been identified
More narrow scope, shorter time frame than a comprehensive assessment
Helps determine if problem still exist or status has change
Includes an appraisal of any new overlooked or misdiagnosed problem
What is the goal of Focussed neurological assessment ?
Rapidly identify any impairment in a persons response to their environment
What are four general areas for a focused neurological assessment?
LOC
Sensory and motor function
Pupillary changes and extraocular movements
Vital signs and pattern of respirations
How can you test sensory?
Q tip
Does this side feel the same as this side?
How can you test for motor function?
Test ability to squeeze
What kind of signs should you assess for during focused neurologica?
Hallucinations, delusions, delirium and or seizure activity
What needs to be identified on cardiac assessment?
Rapidly identify any irregularities in cardiac function
What do you listen to the heart valves for ?
Quality of rate and rhythim
Any abnormal sounds
Apical pulse
What would cause a tract to move to one side?
Pneumothorax, lungs collapse
What to remember to listen to when listening for cardiac assessment?
Aortic pulmonic tricuspid mitral
Where is the apex of the heart?
Mitral valve - where we get the apical pulse
