Focus assessments

Question 1

Neuro focused assessment

Answer 1

• GCS (Glagow coma scale) for sleepy/comatose pt
• Peripheral vision (cover 1 eye)
• PERRLA (pupil equally round reactive to light and accommodation
• Extremeties (up down, gas pedal, push up)
• Facial symmetry
• Sensation
• Headache PQRST
• STIFF NECK
• Dysphagia - trouble swallowing
• Burkes assessment to screen for dysphagia

Recommendation:
Labs:
- Blood glucose, ABG
- CT scan, MRI

Question 2

Respiratory focused assessment

Answer 2

• RR
• O2 Sats and O2 amount
• Breath sounds
• SOB
• Cough (productive or non-productive) sputum/without sputum? What color/thick/thin?
• Labored vs unlabored – high RR? / Low RR
• Retractions – seen in children; muscles between ribs suck in/pull inward during inhalation.

Question 3

Cardiac focused assessment

Answer 3

• Heart sounds x4 (aortic, pulmonic, tricuspid, mitral)
• JVD (jugular vein distention)
• Chest pain? Radiating – Ask PQRST
• Calf pain + increase leg circumference ⇒ DVT