Focused assessments Flashcards
0
Q
Cardiovascular
A
- Blood pressure
- Pulse rate and rhythm
- Jugular veins for distention
- Apical heart rate and rhythm
- Peripheral pulses
- Skin color and temp
- Capillary refill time
- CMS (color, movement, sensation)
- Edema
- Activity tolerance
- Chest pain
1
Q
Respiratory
A
- Oxygen sats
- Lung sounds
- Respiratory rate and depth
- Shortness of breath
- Cough
- Skin color
- Nail bed color
- Ask about cough, sputum, SOB
2
Q
Neurological
A
- Level of consciousness
- Assess orientation
- Pupils
- Speech
- Behavior
3
Q
Musculoskeletal
A
- Pain
- Motor strength of Upper and lower extremities
- Strength of bilateral grips
- Range of motion
- Color, temp, cap refill
- Device (cast)
- Fall risk
4
Q
Nutrition
A
- Nausea or vomiting
- Assess % of diet patient consumed
- Note weight
5
Q
Fluid and electrolyte metabolic pattern
A
- Mucous membranes
- Skin turgor
- IV sites
- Iv type and amount
- Edema
- Lung sounds, crackles
- Note weight
- Note electrolytes
6
Q
Gastrointestinal
A
- Inspect abdomen
- Auscultate bowel sounds
- Light palpation all 4
- Flatus
- Last BM
- Nausea
7
Q
Genitourinary
A
- Difficulty voiding
- If foley is inserted:
- Ask about burning or discomfort
- Assess peri area
- Follow tubing
- Assess color and amount of urine
8
Q
Skin integrity
A
- Overall hygiene condition
- Skin color
- Assess bony prominences for breakdown
- Incision ( location, drainage, dressing)
- Wounds (location, drainage, dressing)
- Drains (type and location)
9
Q
SBAR (situation)
A
Situation
- Name and unit
- Calling about…
- The problem I’m calling about is…
10
Q
SBAR ( background)
A
Background
- Admission date and diagnosis
- Pertinent medical history
- Treatment to date
11
Q
SBAR ( assesment)
A
Assessment
- Recent vitals
- O2 sats
- Focused assessment info
12
Q
SBAR ( recommendation)
A
Recommendation
1. I recommend that you come and assess the patient
