Focused Assessments Flashcards
ABC assessing
Airway
Breathing
Circulation
Why is a focused assessment performed?
when the patient has an illness related to a body system, or when they complain of specific symptoms
What is focused or problem-oriented assessment?
consists of a thorough assessment of a particular health problem and do not cover areas not related to the problem
- already been identified
- Narrow
- status
- new or overlooked/misdiagnosed
Focused Neurological Assessment
- Areas
- rapidly identifying any impairment in a person’s response to the environment
~ 4 General Areas
LOC
sensory (soft/blunt) and motor function (grasps/walking)
pupillary changes and extraocular mvmt
VS and respiration patterns
~ Also
hallucinations, delusions, delirium, or seizure activity
What questions should you ask about HEADACHES?
Ask when?
Ask history of HA?
Is there any medication that helps?
Do you have nausea, blurred vision or visual changes?
S/S of nervous system disorders
Persistent or sudden onset of a headache.
A headache that changes or is different.
Loss of feeling or tingling.
Weakness or loss of muscle strength.
Loss of sight or double vision.
Memory loss.
Impaired mental ability.
Lack of coordination.
Abnormal VS
Assessing the LOC
what is the date? Who is the president? What is going on in the news today? Where are you?
Assessing sensory and motor functions
use of qtip – cotton versus sharp
HG; TW – gait
Assessing pupillary
what is normal size for pupils?
2-4mm in diameter in bright light
4-8 mm in dark
When should you perform a neurological assessment?
Headaches
Loss of sensory/motor functions
double vision
spinal cord
head trauma
Cardiac Focused Assessments
rapidly identify any irregularities in cardiac function
Listen to the heart valves for
quality of rate and rhythm
any abnormal sounds
apical pulse
chest pain?
abnormal sounds like clicks, rubs, extra beats
5 Places of Heart Sounds
Diaphragm then bell
Aortic (2nd intercostal right)
Pulmonic (2nd intercostal left)
Erb’s Point (3rd)
Tricuspid
Mitral (Apex/Apical)
What side of the stethoscope, do you use to check heart sounds
Diaphragm then bell
Mneumonic for 5 Heart Places
All
People
enjoy
Time
Magazine
Erbs is located
3rd intercostal space
Where is the apical pulse located?
Mitral
If you hear 3+ heartbeats, what does that usually mean?
heart failure
Respiratory Focused Assessments
Observe the patient for important respiratory clues: = signs of injury or devices
-Look for abnormalities in the shape of the patient’s chest.
-Check the rate of respiration and quality effort
- cyanosis or pursed-lip breathing
- Ask about the shortness of breath and watch for signs of labored breathing.
- Listen front and back
-Check the patient’s pulse and blood pressure.
-Assess oxygen saturation.
What are you assessing in a respiratory assessment?
checking the respiratory rate, the symmetry, depth and sound (auscultation) of breathing, observes for accessory muscle use and tracheal deviation
Peripheral Neurovascular Assessment
Compartment syndrome
Leg compartments - Lower
anterior, lateral, superficial, and deep posterior
Leg compartments - Upper
anterior (extensor), medial (adductor), posterior (sciatic n.)
6 P’s indicating ischemia
Pain
Paresthesia
Pallor
Pulselessness (dorsalis pedis, posterior tibialis)
Poikilothermia (usually only for compartment syndrome)
Paralysis
Poikilothermia
- part of a muscle has too much pressure inside near a fracture
Poikilothermia means
body/skin temperature
Paresthesias
numbness, tingling
Abdominal Focused Assessments assessed for
pain, nausea, vomiting, injury
changes in appetite or bowel habits
treatments
bowel sounds 5-30 per min
bruits
Bloating, blood in stool, constipation, diarrhea
How do you assess the abdomen
Inspect/Look for scars, drains, tubes
auscultate/Listen
percuss
ANY discomfort or pain
Feel/palpate (palpate area of tenderness last)
What other area besides quadrants do you want to assess/auscultate/palpate?
-Why?
Epigastric
-Bruits
Bruits
not normal could indicate aortic aneurysm, renal artery stenosis or partial occlusion of the femoral arteries
Bruits sound like
swishing sounds with visual pulsations
Start abdominal auscultation in
RLQ
Sign of peritoneal irritation
rebound tenderness
- If pain is present after skin rebounds back after pressing down
The RLQ contains
the lower part of the kidney
part of ascending colon
cecum
vermiform
appendix
uterus
ovaries
The RUQ contains
right lobe of liver
gallbladder
duodenum
bile duct
head of pancreas
kidney and adrenal gland
transverse colon part
ascending colon part
LUQ contains
left lobe of liver
stomach
diaphragm
spleen with adrenal gland
kidney
duodenum
pancreas body
pancreatic duct
transverse and descending colon part
LLQ contains
s. intestine
sigmoid colon
part of descending colon
umbilicus
rectum
bladder
anus
Modified Early Warning Score’s primary purpose
prevent delay in intervention or transfer of critically ill patients
When should you check MEWS?
every 4 hours
MEWS Colors from normal to RRT
GREEN 0-3
Yellow 4
Orange 5
Red 6+
Sepsis
body’s extreme response to an infections
Body’s own immune system attacks its very own tissues and organs in response to infection
Without timely treatment sepsis can rapidly lead to
tissue damage
organ failure
death
When assessing tubes and drains?
Know what kind of tube you are assessing
necessity for pt
follow all tubes, lines, and drains from insertion point to connection point
label all connections to minimize risk of misuse and to rapidly identify what they are
Anything attached to pt, anything going in or coming out must be ________
assessed
Assessing the Pain (PQRST)
Provoke (cause worsening improvement)
- what were you doing when the pain started?
- is the pain worse or has improved w/ or w/o intervention?
Quality (pt’s descriptive words: dull, sharp, crushing)
- Neuropathic
- Somatic
- Visceral
Radiate (localized or travel)
- down extremity or side
- stationary or referred
Severity (scale)
Time (onset, duration, frequency)
- chronic or acute
Neuropathic pain is described as
burning, shooting, numb, fire, electrical, bugs crawling
Somatic pain is described as
achy, throbbing, dull
Visceral pain is described as
squeezing, pressure, cramping, dull, deep, stretching, distension
Telemetry Lead Placement purpose
Not tested
Monitor the cardiac status of any patient at risk for a cardiac event or new onset of a cardiac dysrhythmia
