Health care professionals do focused assessments in response to a specific patient health problem recognized by the assessor as needing further assessment of a body system or systems. Show
Focused Respiratory System AssessmentFigure 2.2 Respiratory systemA focused respiratory system assessment includes collecting subjective data about the patient’s history of smoking, collecting the patient’s and patient’s family’s history of pulmonary disease, and asking the patient about any signs and symptoms of pulmonary disease, such as cough and shortness of breath. Objective data is also assessed. The focused respiratory system assessment in Checklist 19 outlines the process for gathering objective data. Checklist 19: Focused Respiratory System AssessmentDisclaimer: Always review and follow your hospital policy regarding this specific skill.Safety considerations:StepsAdditional Information1. Conduct a focused interview related to history of respiratory disease, smoking, and environmental exposures.Ask relevant questions related to dyspnea, cough/sputum, fever, chills, chest pain with breathing, previous history, treatment, medications, etc.2. Inspect:
Asymmetrical chest expansion may indicate conditions such as pneumothorax, rib fracture, severe pneumonia, or atelectasis. Assess respiration rateWith hypoxemia, cyanosis of the extremities or around the mouth may be noted. 3. Auscultate (anterior and posterior) lungs for breath sounds and adventitious sounds.Fine crackles (rales) may indicate asthma and chronic obstructive pulmonary disease (COPD).Coarse crackles may indicate pulmonary edema. Wheezing may indicate asthma, bronchitis, or emphysema. Low-pitched wheezing (rhonchi) may indicate pneumonia. Pleural friction rub (creaking) may indicate pleurisy. Auscultate anterior chest; blue dots indicate stethoscope placement for auscultationAuscultate posterior chest; blue dots indicate stethoscope placement for auscultation4. Report and document assessment findings and related health problems according to agency policy.Accurate and timely documentation and reporting promote patient safety.Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013Focused Cardiovascular and Peripheral Vascular System AssessmentFigure 2.3 Anatomy of the heartThe cardiovascular and peripheral vascular system affects the entire body. A cardiovascular and peripheral vascular system assessment includes collecting subjective data about the patient’s diet, nutrition, exercise, and stress levels; collecting the patient’s and the patient’s family’s history of cardiovascular disease; and asking the patient about any signs and symptoms of cardiovascular and peripheral vascular disease, such as peripheral edema, shortness of breath (dyspnea), and irregular pulse rate. Objective data is also assessed. The focused cardiovascular and peripheral vascular system assessment in Checklist 20 outlines the process for gathering objective data. Checklist 20: Focused Cardiovascular/Peripheral Vascular System AssessmentDisclaimer: Always review and follow your hospital policy regarding this specific skill.Safety considerations:StepsAdditional Information1. Conduct a focused interview related to cardiovascular and peripheral vascular disease.Ask relevant questions related to chest pain/shortness of breath (dyspnea), edema, cough, fatigue, cardiac risk factors, leg pain, skin changes, swelling in limbs, history of past illnesses, history of diabetes, injury.2. Inspect:
Alterations and bilateral inconsistencies in colour, warmth, movement, and sensation (CWMS) may indicate underlying conditions or injury. Sudden onset of intense, sharp muscle pain that increases with dorsiflexion of foot is an indication of deep venous thrombosis (DVT), as is increased warmth, redness, tenderness, and swelling in the calf. Note: DVT requires emergency referral because of the risk of developing a pulmonary embolism. 3. Auscultate apical pulse for one minute. Note the rate and rhythm.Note the heart rate and rhythm. Identify S1 and S2 and follow up on any unusual findings.Auscultate apical pulse at the fifth intercostal space and midclavicular line4. Palpate the radial, brachial, dorsalis pedis, and posterior tibialis pulses.Absence of pulse may indicate vessel constriction, possibly due to surgical procedures, injury, or obstruction.Assess tibial pulsesAssess pedal pulses5. Report and document assessment findings and related health problems according to agency policy.Accurate and timely documentation and reporting promote patient safety.Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013Focused Gastrointestinal and Genitourinary AssessmentFigure 2.4 Gastrointestinal systemFigure 2.5 Components of the urinary systemThe gastrointestinal and genitourinary system is responsible for the ingestion of food, the absorption of nutrients, and the elimination of waste products. A focused gastrointestinal and genitourinary assessment includes collecting subjective data about the patient’s diet and exercise levels, collecting the patient’s and the patient’s family’s history of gastrointestinal and genitourinary disease, and asking the patient about any signs and symptoms of gastrointestinal and genitourinary disease, such as abdominal pain, nausea, vomiting, bloating, constipation, diarrhea, and characteristics of urine and faeces. Objective data is also assessed. The focused gastrointestinal and genitourinary assessment in Checklist 21 outlines the process for gathering objective data. Checklist 21: Focused Gastrointestinal and Genitourinary AssessmentDisclaimer: Always review and follow your hospital policy regarding this specific skill.Safety considerations:Position patient supine if toleratedStepsAdditional Information1. Conduct a focused interview related to gastrointestinal and genitourinary systems.Ask relevant questions related to the abdomen, urine output, last bowel movement, flatus, any changes, diet, nausea, vomiting, diarrhea.2. Inspect:
Hypoactive or absent bowel sounds may be present after abdominal surgery, or with peritonitis or paralytic ileus. Auscultate abdomen for bowel sounds in all four quadrants4. Palpate abdomen lightly in all four quadrants.Palpate to detect presence of masses and distension of bowel and bladder.Palpate abdomen lightly in all four quadrantsPain and tenderness may indicate underlying inflammatory conditions such as peritonitis. Note: If patient is wearing a brief, ensure it is clean and dry. Inspect skin underneath for signs of redness/rash/breakdown.Note: If patient has a Foley catheter, inspect bag for urine amount, colour, and clarity. Inspect skin at insertion site for redness/breakdown.5. Report and document assessment findings and related health problems according to agency policy.Accurate and timely documentation and reporting promote patient safety.Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013 Focused Musculoskeletal System AssessmentFigure 2.6a Anterior view of musclesFigure 2.6b Posterior view of musclesA focused musculoskeletal assessment includes collecting subjective data about the patient’s mobility and exercise level, collecting the patient’s and the patient’s family’s history of musculoskeletal conditions, and asking the patient about any signs and symptoms of musculoskeletal injury or conditions. Objective data is also assessed. The focused musculoskeletal assessment in Checklist 22 outlines the process for gathering objective data. Checklist 22: Focused Musculoskeletal System AssessmentDisclaimer: Always review and follow your hospital policy regarding this specific skill.Safety considerations:StepsAdditional Information1. Check patient information prior to assessment:
Determine if patient has non-weight-bearing, partial, or full weight-bearing status. Determine if patient ambulates independently, with one-person assist (PA), two-person assist (2PA), standby, or lift transfer. Check alertness, medications, pain. Ask if patient uses walker/cane/wheelchair/crutches. Consider non-slip socks/hip protectors/bed-chair alarm. 2. Conduct a focused interview related to mobility and musculoskeletal system.Ask relevant questions related to the musculoskeletal system, including pain, function, mobility, and activity level (e.g., arthritis, joint problems, medications, etc.).3. Inspect, palpate, and test muscle strength and range of motion:
Evaluate client’s ability to sit up before standing, and to stand before walking, and then assess walking ability. Note strength of handgrip and foot strength for equality bilaterally.Assess strength on plantarflexionAssess strength on dorsiflexionAssess grip strengthNote patient’s gait, balance, and presence of pain. 4. Report and document assessment findings and related health problems according to agency policy.Accurate and timely documentation and reporting promote patient safety.Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013Video 2.1Focused Neurological System AssessmentFigure 2.7 Nervous systemThe neurological system is responsible for all human function. It exerts unconscious control over basic body functions, and it also enables complex interactions with others and the environment (Stephen et al., 2012). A focused neurological assessment includes collecting subjective data about the patient’s history of head injury or dysfunction, collecting the patient’s and the patient’s family’s history of neurological disease, and asking the patient about signs and symptoms of neurological conditions, such as seizures, memory loss (amnesia), and visual disturbances. Objective data is also assessed. The focused neurological assessment in Checklist 23 outlines the process for gathering objective data. What are common assessment findings for a patient with pneumonia?Physical examination may reveal fever or sometimes low body temperature, an increased respiratory rate, low blood pressure, a fast heart rate, or a low oxygen saturation, which is the amount of oxygen in the blood as indicated by either pulse oximetry or blood gas analysis.
What are the expected findings of pneumonia?Common symptoms of pneumonia include fever, chills, shortness of breath, chest pain with breathing, a rapid heart and breathing rate, nausea, vomiting, diarrhea, and a cough that often produces green or yellow sputum (mucus from the lungs); occasionally, the sputum is rust colored.
What are three 3 physical assessment findings that are noted with the development of pneumonia?Physical findings may include the following: Adventitious breath sounds, such as rales/crackles, rhonchi, or wheezes. Decreased intensity of breath sounds. Egophony.
What is focused assessment for pneumonia?A focused respiratory objective assessment includes interpretation of vital signs; inspection of the patient's breathing pattern, skin color, and respiratory status; palpation to identify abnormalities; and auscultation of lung sounds using a stethoscope.
|