Focused Assessments

Question 1

ABC assessing

Answer 1

Airway
Breathing
Circulation

Question 2

Why is a focused assessment performed?

Answer 2

when the patient has an illness related to a body system, or when they complain of specific symptoms

Question 3

What is focused or problem-oriented assessment?

Answer 3

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

Question 4

Focused Neurological Assessment
- Areas

Answer 4

• 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

Question 5

What questions should you ask about HEADACHES?

Answer 5

Ask when?
Ask history of HA?
Is there any medication that helps?
Do you have nausea, blurred vision or visual changes?

Question 6

S/S of nervous system disorders

Answer 6

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

Question 7

Assessing the LOC

Answer 7

what is the date? Who is the president? What is going on in the news today? Where are you?

Question 8

Assessing sensory and motor functions

Answer 8

use of qtip – cotton versus sharp
HG; TW – gait

Question 9

Assessing pupillary

Answer 9

what is normal size for pupils?
2-4mm in diameter in bright light
4-8 mm in dark

Question 10

When should you perform a neurological assessment?

Answer 10

Headaches
Loss of sensory/motor functions
double vision
spinal cord
head trauma

Question 11

Cardiac Focused Assessments

Answer 11

rapidly identify any irregularities in cardiac function

Question 12

Listen to the heart valves for

Answer 12

quality of rate and rhythm
any abnormal sounds
apical pulse
chest pain?
abnormal sounds like clicks, rubs, extra beats

Question 13

5 Places of Heart Sounds
Diaphragm then bell

Answer 13

Aortic (2nd intercostal right)
Pulmonic (2nd intercostal left)
Erb’s Point (3rd)
Tricuspid
Mitral (Apex/Apical)

Question 14

What side of the stethoscope, do you use to check heart sounds

Answer 14

Diaphragm then bell

Question 15

Mneumonic for 5 Heart Places

Answer 15

All
People
enjoy
Time
Magazine

Question 16

Erbs is located

Answer 16

3rd intercostal space

Question 17

Where is the apical pulse located?

Answer 17

Mitral

Question 18

If you hear 3+ heartbeats, what does that usually mean?

Answer 18

heart failure

Question 19

Respiratory Focused Assessments

Answer 19

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.

Question 20

What are you assessing in a respiratory assessment?

Answer 20

checking the respiratory rate, the symmetry, depth and sound (auscultation) of breathing, observes for accessory muscle use and tracheal deviation

Question 21

Peripheral Neurovascular Assessment

Answer 21

Compartment syndrome

Question 22

Leg compartments - Lower

Answer 22

anterior, lateral, superficial, and deep posterior

Question 23

Leg compartments - Upper

Answer 23

anterior (extensor), medial (adductor), posterior (sciatic n.)

Question 24

6 P’s indicating ischemia

Answer 24

Pain
Paresthesia
Pallor
Pulselessness (dorsalis pedis, posterior tibialis)
Poikilothermia (usually only for compartment syndrome)
Paralysis

Question 25

Poikilothermia

Answer 25

- part of a muscle has too much pressure inside near a fracture

Question 26

Poikilothermia means

Answer 26

body/skin temperature

Question 27

Paresthesias

Answer 27

numbness, tingling

Question 28

Abdominal Focused Assessments assessed for

Answer 28

pain, nausea, vomiting, injury changes in appetite or bowel habits treatments bowel sounds 5-30 per min bruits **Bloating, blood in stool, constipation, diarrhea**

Question 29

How do you assess the abdomen

Answer 29

Inspect/Look for scars, drains, tubes auscultate/Listen percuss ANY discomfort or pain Feel/palpate (palpate area of tenderness last)

Question 30

What other area besides quadrants do you want to assess/auscultate/palpate? -Why?

Answer 30

Epigastric -Bruits

Question 31

Bruits

Answer 31

not normal could indicate **aortic aneurysm**, renal artery stenosis or partial occlusion of the femoral arteries

Question 32

Bruits sound like

Answer 32

swishing sounds with visual pulsations

Question 33

Start abdominal auscultation in

Answer 33

RLQ

Question 34

Sign of peritoneal irritation

Answer 34

rebound tenderness - If pain is present after skin rebounds back after pressing down

Question 35

The RLQ contains

Answer 35

the lower part of the kidney part of ascending colon cecum vermiform appendix uterus ovaries

Question 36

The RUQ contains

Answer 36

right lobe of liver gallbladder duodenum bile duct head of pancreas kidney and adrenal gland transverse colon part ascending colon part

Question 37

LUQ contains

Answer 37

left lobe of liver stomach diaphragm spleen with adrenal gland kidney duodenum pancreas body pancreatic duct transverse and descending colon part

Question 38

LLQ contains

Answer 38

s. intestine sigmoid colon part of descending colon umbilicus rectum bladder anus

Question 39

Modified Early Warning Score's primary purpose

Answer 39

prevent delay in intervention or transfer of critically ill patients

Question 40

When should you check MEWS?

Answer 40

every 4 hours

Question 41

MEWS Colors from normal to RRT

Answer 41

GREEN 0-3 Yellow 4 Orange 5 Red 6+

Question 42

Sepsis

Answer 42

body's extreme response to an infections Body's own immune system attacks its very own tissues and organs in response to infection

Question 43

Without timely treatment sepsis can rapidly lead to

Answer 43

tissue damage organ failure death

Question 44

When assessing tubes and drains?

Answer 44

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

Question 45

Anything attached to pt, anything going in or coming out must be ________

Answer 45

assessed

Question 46

Assessing the Pain (PQRST)

Answer 46

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

Question 47

Neuropathic pain is described as

Answer 47

burning, shooting, numb, fire, electrical, bugs crawling

Question 48

Somatic pain is described as

Answer 48

achy, throbbing, dull

Question 49

Visceral pain is described as

Answer 49

squeezing, pressure, cramping, dull, deep, stretching, distension

Question 50

Telemetry Lead Placement purpose *Not tested*

Answer 50

Monitor the cardiac status of any patient at risk for a cardiac event or new onset of a cardiac dysrhythmia