Focussed Assessments Flashcards
What is tool used in carrying out a primary assessment and what does it stand for?
D - Danger R - Response S - Send for help A - Airway B - Breathing C - Circulation D - Disability E - Environment/Exposure
What does FGH stand for and when is it used?
Used in secondary assessment
F - Full set of vitals
G - Give comfort measures
H - History and head-to-toe
What does SAMPLES stand for and when is it used?
Gaining health history
S - Signs/symptoms A - Allergies M - Medications P - Past illnesses L - Last input and output E - Events leading up to illness/injury S - Social and significant family history
Which systems are evaluated in a head to toe assessment?
Neurological Cardiovascular Respiratory Gastrointestinal Renal Integumentary Musculoskeletal
What are the 3 main ways of gathering data from focussed assessments?
Look, listen and feel
What’s involved in a focussed Neurological assessment?
Assess mental state with GLS
Assess drowsiness and sedation score
Assess pain score and properties noting current medications
Compare right and left limb strength
Assess pupil’s reaction to light
Assess cranial nerves, reflexes and sensory function
What is a GCS and when is it used?
Glasgow Coma Scale
It’s used to determine a patient’s level of mental awareness
What does PEARL stand for?
Pupils Equal and Reactive to Light
What does COLDSPA stand for and when is it used?
In assessing pain
C - Character O - Onset L - Location D - Duration S - Severity P - Pattern A - Associated factors
What’s involved in a focussed Cardiovascular assessment?
Assess BP and HR. Noting bounding or thready pulse.
Assess skin tone for paleness, redness or blue tones.
Assess capillary refill.
Look for oedema (water retention, swelling around ankles)
Assess patient’s Temperature
What’s involved in a focussed Respiratory assessment?
Take BR and Sp02 readings
Assess chest wall movement looking for symmetry, use of accessory muscles, depth and pattern.
Assess breathing sounds with stethoscope and without
Assess skin colour centrally and peripherally
Palpating and percussing chest
Listening in intercostal spaces
What types of breathing sounds are there and what do they indicate?
Wheezing: Obstruction on expiration
Stridor (squeaking sound): Obstruction on inspiration
Crackles: Presence of fluid
Pleural friction rub: inflammation on exterior of lungs
What’s involved in a focussed GIT assessment?
Assess current diet and dietary requirements
Assess for nausea and vomiting
Assess abdomen for general appearance, symmetry and feel for tenderness, lumps or protrusions.
Listen for bowel sounds
Assess last movement, normal frequency colour and consistency
Percussing noting dull or hollow sound
What’s involved in a focussed Renal assessment?
Urine: Assess volume, frequency, colour, pain or urgency.
Assess hydration through fluid balance chart
What’s involved in a focussed Integumentary assessment?
Assess for presence of wounds, dressings or pressure injuries.
Assess hair, scalp and nails
Assess skin hydration, oral mucosa and skin turgor
Assess moisture level of skin noting dryness and cracking
