An alternate method of assessment

ASSESSMENT BY BODY SYSTEM

a. Establish rapport by using eye contact- Sitting at the level of the client if possible- Even if you feel rushed; do not convey that

to the client b. Communication is extremely important

I. INTRODUCTION TO THE CLIENT

a. Temperatureb. Pulsec. Respirationsd. Blood Pressuree. Pain Assessmentf. Weight/Heightg. O₂ Saturation

II. VITAL SIGNS

a. Level of Consciousness1. Stimulus Response

b. Pupils (PERRLA)-examination of clients eyes2. Pupils Equal Round Reactive to Light and

Accommodation3. Means the ability of the eyes to focus on objects

that are close up and faraway

III. NEUROLOGICAL ASSESSMENT

Glasgow Coma Scale

Response Score

Eye Opening SpontaneousTo verbal commandTo painNo response

4321

Motor Response To verbal commandTo painful stimuli-- Localizes pain- Flexes and withdraws- Assumes Flexor

posturing- Assumes Extensor

posturingNo response

6

54321

Verbal Response(arouse patient with painful stimuli if necessary)

Oriented and ConversesDisoriented and ConversesUses Inappropriate WordsMakes Incomprehensible SoundsNo response

54321

a. Pulses- Apical, Radial, Pedal Quality & Rate Bilaterally

b. Capillary Refi llc. Neck Veinsd. Edema-check feet, hands, scrotume. Heart Sounds-lub/dub, rhythm, murmursf. Sighs and Symptoms of Shock

1.Increased heart rate2.Decreased blood pressure

g. Cool, clammy skin

IV. CARDIAC ASSESSMENT

Can be done on the fingers or toesPress down on the nail bedColor will blanchAssess the time for the color

to returnCapillary refi ll should return in

3 seconds or lessDelay in capillary refi ll may

indicate impaired circulation

B. CAPILLARY REFILL

Neck veins should be checked by having patient sit at a 45 degree angle

In this position, the jugular veins should be flatDistended neck veins at 45 degrees are an indicator

of over hydration or fluid overload

C. NECK VEINS

Distended Veins Flattened Veins

NECK VEINS

a. Facial Symmetry1. Check teeth, raise eyebrows

b. Hand gripsc. Movements & Strength of Extremities

2. Patients extends arms, check reflexes

V. MOTOR FUNCTIONING

a. Inspection of skin color, barrel chest of emphysemab. Auscultation

1.Lung sounds-wales/crackles, wheezesc. Sputum-color consistencyd. Cough-productive, non productivee. Oxygen administration and response

VI. RESPIRATORY ASSESSMENT

a. Inspection- flat, round, distendedb. Auscultation

1. Bowel sounds; 4 quadrants- hypoactive, active, hyperactive, absent

2. Listen for abdominal aorta bruitc. Palpation- pain?, deep to determine liver marginsd. Percussion- air, fluid?e. Nausea, Vomiting, Dyspepsia, Anorexiaf. Nutrition-intake, pain when eating, appetiteg. Lab Values-protein, prealbumin(blood test)

VII. GASTROINTESTINAL & ABDOMINAL ASSESSMENT

a. Intake and Outputb. Peripheral Edemac. Diaphoresis (excessive sweating)d. I.V. Sitee. Lab Values- electrolytes

VIII. FLUIDS & ELECTROLYTES

a. Urinary

Assessment

b. Stool

c. Diaphoresisd. Drainage form

dressing, drains

e. Lab Values

a. Color, odor, amountb. Last bowel movement

color, character and consistency

c. Excessive sweating

e. Blood, Urea, Nitrogen (BUN), Creatinine,

blood in Stool?

IX. EXAMINATION

a. Muscle Strength1. Mobile? Immobile

X. MUSCULOSKELETAL ASSESSMENT

a. Sensesb. Diabetic

c. Thyroid

a. Hearing, visionb. Glucose levels, altered

levels of consciousness, Feet/skin

c. Monitor heart rate & blood pressure

XI. ENDOCRINE/REGULATION

a. Decubiti (when in lying down position)

b. Nutrition

a. redness, lesions, skin to muscle & to bone

b. Intake, likes/dislikes, output

XII. INTEGUMENTARY SYSTEM

a. Aff ect of illness on role; such as work, familyb. Inappropriate independence, dependence?c. Check for depression, suicidal ideation of needed

XIII. PSYCHOSOCIAL ASPECTS