Select the 4 assessment findings that require immediate follow up by the nurse
A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient’s hemodynamic status and the context. The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition. Any unusual findings should be followed up with a focused assessment specific to the affected body system. Show A physical examination involves collecting objective data using the techniques of inspection, palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013). Checklist 17 outlines the steps to take. Checklist 17: Head-to-Toe AssessmentDisclaimer: Always review and follow your hospital policy regarding this specific skill.Safety considerations:
StepsAdditional Information1. General appearance:
2. Skin, hair, and nails:
Redness of the skin at pressure areas such as heels, elbows, buttocks, and hips indicates the need to reassess patient’s need for position changes. Unilateral edema may indicate a local or peripheral cause, whereas bilateral-pitting edema usually indicates cardiac or kidney failure. Check hair for the presence of lice and/or nits (eggs), which are oval in shape and adhere to the hair shaft. 3. Head and neck:
Slow pupillary reaction to light or unequal reactions bilaterally may indicate neurological impairment. Dry mucous membranes indicate decreased hydration. Facial asymmetry may indicate neurological impairment or injury. Unusual findings should be followed up with a focused neurological system assessment. 4. Chest:
Use of accessory muscles may indicate acute airway obstruction or massive atelectasis. Jugular distension of more than 3 cm above the sternal angle while the patient is at 45º may indicate cardiac failure. The presence of crackles or wheezing must be further assessed, documented, and reported. Unusual findings should be followed up with a focused respiratory assessment. Auscultate anterior chest; blue dots indicate stethoscope placement for auscultationAuscultate posterior chest; blue dots indicate stethoscope placement for auscultationAuscultate apical pulse at the fifth intercostal space and midclavicular lineNote the heart rate and rhythm, identify S1 and S2, and follow up on any unusual findings with a focused cardiovascular assessment. 5. Abdomen:
Hyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileum. Hypoactive or absent bowel sounds may be present after abdominal surgery, or with peritonitis or paralytic ileus. Pain and tenderness may indicate underlying inflammatory conditions such as peritonitis. Unusual findings in urine output may indicate compromised urinary function. Follow up with a focused gastrointestinal and genitourinary assessment. Unusual findings with bowel movements should be followed up with a focused gastrointestinal and genitourinary assessment. Auscultate abdomen6. Extremities:
Palpate pulses for symmetry in rate and rhythm. Asymmetry may indicate cardiovascular conditions or post-surgical complications. Unequal handgrip and/or foot strength may indicate underlying conditions, injury, or post-surgical complications. CWMS: colour, warmth, movement, and sensation of the hands and feet should be checked and compared to determine adequacy of perfusion. Check skin integrity and pressure areas, and ensure follow-up and in-depth assessment of patient mobility and need for regular changes in position. Assess dorsiflexionAssess plantarflexionAssess CWMS – colour, warmth, movement, and sensationAssess bilateral hand strengthPalpate and inspect capillary refill and report if more than 3 seconds. Assess pedal pulsesCheck capillary refillTo check capillary refill, depress the nail edge to cause blanching and then release. Colour should return to the nail instantly or in less than 3 seconds. If it takes longer, this suggests decreased peripheral perfusion and may indicate cardiovascular or respiratory dysfunction. Unusual findings should be followed up with a focused cardiovascular assessment. Clubbing of nails, in which the nails present as straightened out to 180 degrees, with the nail base feeling spongy, occurs with heart disease, emphysema, and chronic bronchitis. 7. Back area (turn patient to side or ask to sit up or lean forward):
Check skin integrity and pressure areas, and ensure follow-up and in-depth assessment of patient mobility and need for regular changes in position. 8. Tubes, drains, dressings, and IVs:
Assess wounds for large amounts of drainage or for purulent drainage, and provide wound care as indicated. What are the five steps of patient assessment?emergency call; determining scene safety, taking BSI precautions, noting the mechanism of injury or patient's nature of illness, determining the number of patients, and deciding what, if any additional resources are needed including Advanced Life Support.
What are 3 actions by the nurse should take during the assessment and data collection steps?The nurse should review the clients history during the assessment/ data collection step of the nursing process.. Recognize patterns or trends.. Compare the data with expected standards or reference ranges.. Compare the data with expected standards or reference ranges.. What is included in a nursing assessment?The nursing assessment includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient. Subjective and objective data collection are an integral part of this process.
Which assessments would the nurse include in a focused assessment for a client who has sustained a head injury?Assessment of the head injury patient should include airway, cervical spine protection, breathing, circulation, and haemorrhage control followed by the GCS.
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