Focused Assessments

Question 1

what is different about a focused assessment?

Answer 1

• collect data about a problem that has already been identified
• more narrow scope; shorter time frame than a comprehensive assessment
• helps determine if problem still exists or status has changed
• includes an appraisal of any new, overlooked, or misdiagnosed problem

Question 2

focused neurological assessment

Answer 2

• identity deficit: rapidly identify any impairment in a person’s response to their environment
• 4 general areas:
  – level of consciousness
  – sensory and motor function
  – pupillary changes and extraocular movements
  – vital signs and pattern of respiration
• there may also be a need to assess for signs of hallucinations, delusions, delirium, and/or serizure activity

Question 3

focused cardiac

Answer 3

• identity deficit: rapidly identify any irregularities in cardiac function
• listen to the heart valves for:
  – quality of rate and rhythm
  – any abnormal sounds
  – apical pulse
• describe and record abnormal sounds such as clicks, rubs, extra beats, ask questions about any chest pain
  (aortic: 2nd intercostal to right of sternum,
  pulmonic: 2nd intercostal space to left of sternum,
  tricuspid: ____,
  mitral: ____ apical pulse)

Question 4

focused respiratory

Answer 4

• look for signs of injury and check symmetry of chest expansion, note any difficulty breathing or use of axillary muscles
• assess rate and quality of respiratory effort, look for cyanosis or pursed-lip breathing (count breaths, check O2 sats, if below 90 have them sit up, take deep breathes, check again, if not up, put on another finger, check again, if not up, put on oxygen)
• is the patient able to speak in complete sentences, listen both anteriorly and posteriorly
• palpate only if injury has occurred or any visible signs of irregularity in symmetry
  (1. check rate of respiration,
  2. look for abnormalities in shape of patient’s chest,
  3. ask about shortness of breath and watch for signs of labored breathing,
  4. check the patient’s pulse and blood pressure,
  5. assess oxygen saturation)

Question 5

peripheral neurovascular assessment

Answer 5

compartment syndrome: part of a muscle has too much pressure inside it, normally brought on by fracture in extremity
- 6 P’s indicating ischemia:
– pain
– paresthesias (numbness or tingling)
– palor
– pulselessness
– poikilothermia: body can’t maintain core body temperature,
– paralysis
(check pain against same body part on other side like other ankle, other elbow, other wrist, not something completely different)

Question 6

focused abdominal

Answer 6

assess for:
- pain, nausea, vomiting, injury
- changes in appetite or bowel habits
- any treatment
- listen for bowel sounds
- listen for any bruits

Question 7

tubes and drains

Answer 7

• know what kind of tube you are assessing
• why is it necessary for patient
• 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 patient must be assessed, anything going in or coming out must be assessed)

Question 8

something about the pain rating scale

Answer 8

something something

Question 9

modified early warning score (MEWS)

Answer 9

• primary purpose is to prevent delay in intervention or transfer of critically ill patients
• sepsis is body’s extreme response to an infection: 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 and death

Question 10

telemetry lead placement

Answer 10

• purpose: monitor the cardiac status of any patient at risk for a cardiac event or new onset of a cardiac dysrhythmia

Question 10

telemetry lead placement

Answer 10

• purpose: monitor the cardiac status of any patient at risk for a cardiac event or new onset of a cardiac dysrhythmia

Question 11

cardiac NII

Answer 11

• inspect the chest
• listen in 4 locations for at least 2 complete cycles (lubdub lubdub)
  – auscultate the apical pulse

Question 12

neuro NII

Answer 12

• assess LOC
  – eye opening, verbal response and orientation
• assess motor function
  – handgrasp, toe wiggle, flexion and extension with resistance
• assess sensation
  – pain, touch, temp, pressure

Question 13

respiratory NII

Answer 13

• resp. rate and O2 sat
• inspect upper airway (look in mouth)
• inspect chest
• auscultate chest (listen posterior and anterior)

Question 14

abdominal NII

Answer 14

• inspect abdomen
• auscultate abdomen (listen in each quadrant)
• palpate abdomen
• interview patient about bowel habits

Question 15

peripheral neurovascular NII

Answer 15

assess the 6 P’s
- pain
- pallor
- pulse
- parasthesia (numbness or tingling)
- paralysis
- poikilothermia