What Should the Nurse Do to Understand the Nature of a Clientã¢â‚¬â„¢s Pain?

Chapter 2. Patient Assessment

two.7 Focused Assessments

Health intendance professionals do focused assessments in response to a specific patient health trouble recognized past the assessor as needing further cess of a body arrangement or systems.

Focused Respiratory Arrangement Assessment

Figure two.2 Respiratory arrangement

A focused respiratory system cess includes collecting subjective information about the patient'due south history of smoking, collecting the patient's and patient's family'south history of pulmonary illness, and asking the patient about whatever signs and symptoms of pulmonary illness, 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 information.

Checklist 19: Focused Respiratory Organisation Cess

Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Rubber considerations: Perform hand hygiene. Check room for contact precautions Introduce yourself to patient. Ostend patient ID using 2 patient identifiers (e.m., name and date of nativity). Explicate process to patient. Be organized and systematic in your assessment. Utilize appropriate listening and questioning skills. Mind and attend to patient cues. Ensure patient's privacy and dignity. Assess ABCCS/suction/oxygen/safety. Utilise principles of asepsis and safety. Bank check vital signs. Complete necessary focused assessments.
Steps		Additional Information
one. Conduct a focused interview related to history of respiratory affliction, smoking, and environmental exposures.		Ask relevant questions related to dyspnea, cough/sputum, fever, chills, breast pain with animate, previous history, treatment, medications, etc.
two.Inspect: For employ of accompaniment muscles and work of breathing Configuration and symmetry of the chest Respirations for charge per unit (ane infinitesimal), depth, rhythm pattern Skin colour of lips, face up, hands, feet O2 saturation with a pulse oximeter		Patients in respiratory distress may have an anxious expression, pursed lips, and/or nasal flaring. Asymmetrical chest expansion may indicate weather such as pneumothorax, rib fracture, severe pneumonia, or atelectasis. Assess respiration rate With hypoxemia, cyanosis of the extremities or around the mouth may exist 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 bespeak 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 auscultation Auscultate posterior breast; blue dots indicate stethoscope placement for auscultation
iv. Report and document assessment findings and related health issues co-ordinate 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 Cardiovascular and Peripheral Vascular System Assessment

Effigy 2.iii Anatomy of the heart

The cardiovascular and peripheral vascular system affects the entire body. A cardiovascular and peripheral vascular system assessment includes collecting subjective data near the patient's diet, diet, exercise, and stress levels; collecting the patient's and the patient's family unit's history of cardiovascular disease; and request the patient about any signs and symptoms of cardiovascular and peripheral vascular disease, such as peripheral edema, shortness of jiff (dyspnea), and irregular pulse charge per unit. Objective information is also assessed.

The focused cardiovascular and peripheral vascular system assessment in Checklist xx outlines the process for gathering objective data.

Checklist twenty: Focused Cardiovascular/Peripheral Vascular System Assessment

Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Rubber considerations: Perform manus hygiene. Check room for contact precautions. Innovate yourself to patient. Ostend patient ID using two patient identifiers (eastward.g., name and date of birth). Explain process to patient. Be organized and systematic in your assessment. Apply appropriate listening and questioning skills. Listen and attend to patient cues. Ensure patient'south privacy and nobility. Appraise ABCCS/suction/oxygen/safety. Apply principles of asepsis and safety. Check vital signs. Complete necessary focused assessments.
Steps		Additional Information
ane. Bear a focused interview related to cardiovascular and peripheral vascular disease.		Ask relevant questions related to chest hurting/shortness of jiff (dyspnea), edema, cough, fatigue, cardiac risk factors, leg pain, pare changes, swelling in limbs, history of by illnesses, history of diabetes, injury.
2. Inspect: Face, lips, and ears for cyanosis Chest for deformities, scars Bilateral arms/hands, noting CWMS, edema, colour of nail beds, and capillary refill Bilateral legs, noting CWMS, edema to lower legs and feet, presence of superficial distended veins, colour of nail beds, and capillary refill calf size/pain for signs of DVT		Cyanosis is an indication of decreased perfusion and oxygenation. Assess capillary refill Appraise bilateral lower legs Alterations and bilateral inconsistencies in colour, warmth, movement, and sensation (CWMS) may signal 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. Notation: DVT requires emergency referral because of the run a risk of developing a pulmonary embolism.
3. Auscultate apical pulse for aneminute. Note the rate and rhythm.		Note the heart charge per unit and rhythm. Identify S1 and S2 and follow up on whatsoever unusual findings. Auscultate apical pulse at the fifth intercostal infinite and midclavicular line
4. Palpate the radial, brachial, dorsalis pedis, and posterior tibialis pulses.		Absence of pulse may signal vessel constriction, possibly due to surgical procedures, injury, or obstruction. Assess tibial pulses Assess pedal pulses
5. Report and certificate cess findings and related health bug co-ordinate to bureau policy.		Authentic and timely documentation and reporting promote patient prophylactic.
Data source: Cess Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013

Focused Gastrointestinal and Genitourinary Assessment

Figure 2.iv Gastrointestinal system

Figure 2.v Components of the urinary system

The 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 near the patient's diet and practice levels, collecting the patient's and the patient'due south family's history of gastrointestinal and genitourinary disease, and asking the patient about any signs and symptoms of gastrointestinal and genitourinary disease, such as intestinal pain, nausea, airsickness, 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 Assessment

Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Condom considerations: Perform mitt hygiene. Check room for contact precautions. Introduce yourself to patient. Confirm patient ID using two patient identifiers (e.one thousand., name and date of birth). Explain process to patient. Be organized and systematic in your assessment. Use appropriate listening and questioning skills. Heed and attend to patient cues. Ensure patient's privacy and nobility. Assess ABCCS/suction/oxygen/safety. Utilise principles of asepsis and safety. Cheque vital signs. Consummate necessary focused assessments.
Position patient supine if tolerated
Steps		Boosted Data
i. Carry a focused interview related to gastrointestinal and genitourinary systems.		Ask relevant questions related to the abdomen, urine output, last bowel movement, flatus, any changes, nutrition, nausea, vomiting, diarrhea.
2. Inspect: Abdomen for distension, striae, scars, contour, and symmetry Observe any abdominal movements associated with respiration, or any pulsations or peristaltic waves		Abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, and pancreatitis. Markedly visible peristalsis with abdominal distension may indicate intestinal obstruction.
3. Auscultate a bdomen for bowel sounds in all four quadrants before palpation.		Hyperactive bowel sounds may point bowel obstruction, gastroenteritis, or subsiding paralytic ileus. Hypoactive or absent bowel sounds may be present later on abdominal surgery, or with peritonitis or paralytic ileus. Auscultate abdomen for bowel sounds in all four quadrants
4. Palpate abdomen lightlyin all 4 quadrants.		Palpate to detect presence of masses and distension of bowel and bladder. Palpate abdomen lightly in all four quadrants Hurting and tenderness may indicate underlying inflammatory conditions such every bit peritonitis.
Note: If patient is wearing a cursory, ensure it is clean and dry. Inspect skin underneath for signs of redness/rash/breakdown.
Notation: If patient has a Foley catheter, audit bag for urine amount, color, and clarity. Inspect skin at insertion site for redness/breakup.
v. Report and document assessment findings and related health issues according to bureau policy.		Accurate and timely documentation and reporting promote patient prophylactic.
Data source: Cess Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013

Focused Musculoskeletal Arrangement Assessment

Figure two.6a Anterior view of muscles

Figure 2.6b Posterior view of muscles

A focused musculoskeletal assessment includes collecting subjective data almost the patient'due south mobility and do level, collecting the patient'south and the patient'south family's history of musculoskeletal weather condition, and request the patient well-nigh any signs and symptoms of musculoskeletal injury or weather condition. Objective data is also assessed.

The focused musculoskeletal cess in Checklist 22 outlines the process for gathering objective information.

Checklist 22: Focused Musculoskeletal System Assessment

Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Safety considerations: Perform hand hygiene. Bank check room for contact precautions. Innovate yourself to patient. Confirm patient ID using two patient identifiers (eastward.g., proper name and engagement of nativity). Explain process to patient. Be organized and systematic in your assessment. Utilise advisable listening and questioning skills. Listen and nourish to patient cues. Ensure patient's privacy and dignity. Assess ABCCS/suction/oxygen/safety. Apply principles of asepsis and safety. Check vital signs. Complete necessary focused assessments.
Steps		Boosted Information
1. Check patient information prior to assessment: Activity order Mobility status Falls risk Need for assistive devices		Determine patient's activeness as tolerated (AAT)/bed rest requirements. Patient position prior to continuing Determine if patient has non-weight-bearing, partial, or full weight-bearing status. Make up one's mind if patient ambulates independently, with one-person assist (PA), two-person assist (2PA), standby, or lift transfer. Bank check alertness, medications, hurting. Enquire if patient uses walker/cane/wheelchair/crutches. Consider not-slip socks/hip protectors/bed-chair warning.
two. Deport a focused interview related to mobility and musculoskeletal system.		Ask relevant questions related to the musculoskeletal organization, including hurting, function, mobility, and activeness level (e.g., arthritis, joint problems, medications, etc.).
iii. Inspect, palpate, and test muscle strength and range of motility: Bilateral handgrip strength Range of motion (ROM) of knees Dorsi/plantar flexion Evaluate client'due south power to sit up before standing, and to stand before walking, then appraise walking ability.		Annotation strength of handgrip and pes strength for equality bilaterally. Appraise strength on plantarflexion Assess strength on dorsiflexion Assess grip strength Note patient's gait, balance, and presence of hurting.
4. Report and document assessment findings and related health issues according to agency policy.		Accurate and timely documentation and reporting promote patient safe.
Data source: Cess Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013

Video 2.1

Focused Neurological System Assessment

Figure ii.seven Nervous system

The neurological system is responsible for all man role. Information technology exerts unconscious control over basic body functions, and it too enables complex interactions with others and the environment (Stephen et al., 2012). A focused neurological assessment includes collecting subjective information most the patient's history of head injury or dysfunction, collecting the patient's and the patient's family unit'due south history of neurological disease, and asking the patient nearly signs and symptoms of neurological conditions, such as seizures, retentiveness loss (amnesia), and visual disturbances. Objective data is also assessed.

The focused neurological assessment in Checklist 23 outlines the process for gathering objective data.

Checklist 23: Focused Neurological System Assessment

Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Safety considerations: Perform manus hygiene. Bank check room for contact precautions. Introduce yourself to patient. Confirm patient ID using two patient identifiers (e.g., proper noun and date of birth). Explain process to patient. Be organized and systematic in your assessment. Use advisable listening and questioning skills. Listen and attend to patient cues. Ensure patient's privacy and dignity. Assess ABCCS/suction/oxygen/safety. Apply principles of asepsis and rubber. Check vital signs. Complete necessary focused assessments.
Steps		Additional Information
i. Conduct a focused interview related to the neurological organization.		Ask relevant questions related to past or contempo history of head injury, neurological illness, or symptoms, confusion, headache, vertigo, seizures, recent injury or fall, weakness, numbness, tingling, difficulty swallowing (dysphagia) or speaking (dysphasia), and lack of coordination of body movements. Focused interview
two. Assess mental health condition.		Assess mental status past observing the patient's appearance, attitude, activity (behaviour), mood and affect, and asking questions similar to those outlined in this example of a mini-mental state examination (MMSE).
3. Assess neurological role using the Glasgow Blackout Scale (GCS): Assess best eye-opening response. Appraise all-time motor response. Assess best verbal response.		All-time heart-opening response Tape "C" if eyes airtight due to swelling. Spontaneously 4 To speech three To pain 2 No response i All-time motor response (to painful stimuli) Press at fingernail bed and record best upper-limb response. Obeys verbal control vi Localizes hurting five Flexion – withdrawal 4 Flexion – abnormal three Extension – abnormal 2 No response one Best verbal response Record "Eastward" if endotracheal tube is in place, and "T" if tracheostomy is in place. Oriented ten 3 (to person, time, and place) five Chat – confused 4 Speech – inappropriate 3 Sounds – incomprehensible ii No response 1 Glasgow Coma Scale adapted from Jarvis et al., 2014, p. 699.
4. Annotation patient's LOC (level of consciousness, oriented 10 3), general appearance, and behaviour.		Notation hygiene, training, speech patterns, facial expressions.
5. Assess pupils for size, equality, reaction to light (PERL), and consensual reaction to calorie-free.		Unequal pupils may indicate underlying neurological illness or injury. Appraise pupillary reaction to low-cal
six. Appraise motor strength and awareness. Arms and legs for force (compare bilaterally) Handgrips, drift Extremities for sensation, numbness, tingling		Unequal motor forcefulness and unusual sensation may signal underlying neurological disease or injury, such every bit stroke or caput injury. Assess motor strength and sensation of extremities Assess motor strength and sensation of extremities Appraise motor forcefulness and sensation of extremities
7. Report and document assessment findings and related wellness problems according to agency policy.		Accurate and timely documentation and reporting promote patient safety.
Information source: Cess Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013

Video 2.two

1. Your patient complains of stomach pain during your head-to-toe cess. What would be your next steps?
2. You notice that your patient seems lethargic during your head-to-toe assessment. What would be your next steps?

Attributions

Figure 2.two
The respiratory arrangement past LadyofHats is in the public domain.

Figure 2.iii
Sectional anatomy of the heart by Blausen Medical Communications, Inc. is used under a CC By 3.0 licence.

Figure two.4
Digestive organisation diagram by Mariana Ruiz Villarreal is in the public domain.

Figure 2.v
Urinary system is in the public domain.

Figure ii.six
Anterior and posterior views of muscles by OpenStax Higher is used under a CC BY 3.0 licence.

Figure ii.7
Nervous system diagram by William Crochot is used under a CC BY SA 4.0 licence.

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Source: https://opentextbc.ca/clinicalskills/chapter/2-5-focussed-respiratory-assessment/

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