*Original post released 5/5/2020
One of the most important tools a nurse can have is their ability to perform focused assessments. Sometimes, this can mean the difference between life and death for your patient. There are multiple key areas where assessments should be focused: the cardiac system, the pulmonary system, the neurological system, the GI system, the GU system, and the integumentary system. If your patient expresses onset of a new health complaint, it is imperative to perform a new head-to-toe generalized assessment as well as a focused assessment of the involved system. Always remember to treat the patient as they are presenting and don’t just base interventions on the monitor. Keep in mind that these assessment points and possible interventions are not all inclusive. Your assessment needs to be individualized to your patient, and this article cannot cover every possible adverse situation you might encounter.
Cardiac System Focused Assessment
Initially, check the patient’s blood pressure (BP) and heart rate (HR). If connected to leads that allow for continuous monitoring, be sure to examine their heart rhythm and note any ectopy. Depending on the rhythm, there are specific treatments. Ectopy could represent the presence of electrolyte imbalances.
Make sure you’re aware of the patient’s PRN medications at your disposal to use in different situations. For example, if the patient’s HR is elevated, typically above 110 or 120 bpm, they may have metoprolol on their E-MAR to help lower it. Or if their BP is above a certain threshold, they may have a med like hydralazine to lower their BP. If the patient has ectopy, it is likely that an electrolyte panel is indicated so replacements can be given as needed.
Also be sure to assess the patient’s pulses at the point of maximal impulse (compared to radial) as well as all peripheral pulses. If abnormal, a doppler examination may be warranted. If there is a discrepancy between pulses bilaterally, check the color, temperature, and for any other symptoms that may indicate thrombosis such as calf pain with flexion of the foot.
Pulmonary System Focused Assessment
First things first, make sure the patient is able to protect their airway. If they are unable to do so, this indicates an emergency situation. Assess the patient’s lung sounds if their breathing has changed, effort has increased, or the patient audibly sounds different. Are they diminished on one side? Are there adventitious breath sounds such as rhonchi, wheezing, crackles, rales, or stridor?
Your assessment will likely play into the doctor’s decision for intervention. Possible interventions involving the pulmonary system include administration of a breathing treatment, suctioning the oral cavity or tracheostomy/endotracheal tube, initiation or continuation of BiPAP/CPAP, medication administration (Ex: Lasix), chest tube insertion or troubleshooting, insertion of an oropharyngeal or nasopharyngeal airway, and intubation.
Nervous System Focused Assessment
Be sure to assess the patient’s level of consciousness and their overall GCS score. Is there an acute change in their mental status? If so, one of the most important interventions you can do is assess for stroke. Think “BE FAST” and assess immediately. Is their balance affected? Is there unilateral eye/facial drooping? Can they hold their arms outstretched without drifting or rotating? Is their speech slurred, or are they even able to produce coherent speech at all? If your assessment seems off in any way, time is of the essence with these symptoms. Time is equivalent to the viability of brain tissue.
Assess the patient’s cranial nerve function, extremity strength and range of motion, speech, gait, behavior, mood, level of orientation, reflexes, etc. Assess as many of these aspects as possible. Is there pain? Assess the intensity and characteristics of the pain. There are also special situations that may involve seizure activity, adverse med effects, ICP monitoring, and more. Possible interventions could be the administration of psychiatric medications when warranted, sedation, antiepileptic medication administration, tele-neuro conferencing, etc. Initiate any safety precautions as they are indicated (Ex: seizure, fall risk, suicide precautions).
Gastrointestinal System Assessment
Are the patient’s bowel sounds present, absent, hyperactive, hypoactive? Have they had a bowel movement, and if so what are the characteristics of the stool? If not, when was the last time they had a bowel movement? It is possible that they may be constipated or impacted. Feel the abdomen. Is it firm, rigid, distended? Can you feel any masses? Are they experiencing nausea and vomiting? Is there blood in their emesis or stool?
Possible interventions after gastrointestinal assessment include diarrhea/constipation/nausea medication administration, digital removal if impacted, dietary modification, etc. Other actions include placing the patient of a nothing-by-mouth status and aspiration precautions. I urge you to consider having suction set up in the patient’s room in cases of vomiting to prevent aspiration of emesis into the lungs. To also help with preventing this, increase the elevation of the head of the bed to a minimum of 30 degrees.
Genitourinary System Focused Assessment
Is your patient able to void, and if so when was the last time they voided? It’s possible they may be retaining urine in the bladder which can be detected via bladder scan. In cases of retention, a straight catheter procedure is likely indicated. If they are able to void, what are the characteristics of their urine? Do they have any symptoms when they void (Ex: burning, pain, itching, etc.)? These may indicate the presence of an infection which can lead to urosepsis among other complications if not treated. Be sure to perform catheter/perineal care and utilize that situation as an opportunity to further your assessment.
Be sure to monitor the patient’s intake and output as well as electrolyte levels to prevent imbalances from occuring. Correct imbalances as indicated and ordered by the physician. Other possible interventions include bladder irrigation, medication administration to help with retention like tamsulosin or those to help with fluid volume excess like furosemide, initiation of consultations with nephrology/urology, and ensuring that there are no depending (low hanging) loops in the catheter tubing.
Integumentary System Focused Assessment
Be sure to examine the patient’s back, groin, head, heels, and other areas of bony prominences to look for evidence of skin breakdown. If there are any areas of breakdown or redness, strongly consider placing a Mepilex dressing over the site prophylactically to prevent further deterioration. If the patient has any wounds, perform an in depth assessment of the wound’s characteristics and its dressing. Re-dress if needed. Be sure to turn the patient frequently or encourage range of motion exercises and ambulation if able. When the patient is unable to ambulate, try using the bed’s rotation feature to provide continuous shifting of the patient’s weight off their pressure points.
Interventions for the integumentary system can include protection of the common pressure areas as expressed above. If indicated, change the patient’s dressings or reinforce them as needed. Turning the patient and/or using pillows/wedges to shift the patient’s weight can also be done. Also, consider using heel protectors or boots to not only help with preventing foot drop but heel breakdown as well.
As previously stated, this article cannot contain every point for focused assessment. This is why it is imperative to continuously practice and hone in on your assessment skills!
XOXO
Andra Alyse
The Study Nurse 