Focused Assessment (NII) Flashcards
Cardiovascular focused assessment steps (2)
Critical Elements
1.Auscultate heart sound at 4 correct landmarks
2. Count Apical heart rate
Abdominal Focus Assessment steps (3)
Critical Elements
- Inspect abdomen for size, shape, discoloration, scars, wounds, and lesions
2.Auscultate for the presence or absences of bowel and vascular sounds in the epigastric regions and all four quadrants of the abdomen - Perform light palpation over the epigastric region and all four quadrants of the abdomen to assess for presence of tenderness, guarding, distention, or masses
Neurological focused assessment (3)
Critical elements
- Assess level of consciouesness
- Assess motor functions
- Assess sensation
Pain focused assessment step (1)
Critical elements
- Perform pain assessment
Peripheral Neurovascular Focused Assessment step (1)
Critical Element
- Assess six Ps
Respiratory Focused Assessments steps (6)
Critical elements
- Assess oxygen saturation
- Obtain respiratory rate
- Observe depth, rhythm, and symmetry of chest movement
- Ausultate anterior and posterior lungs fields
- Identify presence or absence of adventitious respiratory sounds
- Assess for the presence of respiratory distress
How long do you listen to the four quadrants and epigastric region
5-20 seconds
How long is it to be considered absent bowel sound
3-5 minutes
How long do you listen to the four heart sounds?
2 complete cycles
How long do you listen to the apical heart rate
1 full minute
What must you do before putting your stethoscope on a patient?
Clean it
When assessing level of consciousness, what all do you check? (3)
Eye opening, Verbal response, and Orientation
When assessing motor function, what all for you check (2)
- hand grasp and toe wiggle (HGTW)
- Flexion and extension
When assessing sensation, what all do you check?(4)
Pain, temperature, touch, and pressure
Pain Assessment
What does PQRST mean?
-Provoke
-Quality
-Radiate
-Severity
-Time
