{"id":311,"date":"2015-02-24T17:59:31","date_gmt":"2015-02-24T17:59:31","guid":{"rendered":"http:\/\/opentextbc.ca\/clinicalskills\/?post_type=chapter&p=311"},"modified":"2021-10-15T17:02:14","modified_gmt":"2021-10-15T17:02:14","slug":"2-5-focussed-respiratory-assessment","status":"publish","type":"chapter","link":"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/2-5-focussed-respiratory-assessment\/","title":{"raw":"2.7 Focused Assessments","rendered":"2.7 Focused Assessments"},"content":{"raw":"Health care professionals do focused assessments in response to a specific patient health problem recognized by the assessor as needing\u00a0further assessment\u00a0of a body system or systems.\r\n

Focused Respiratory System Assessment<\/h2>\r\n[caption id=\"attachment_6716\" align=\"aligncenter\" width=\"528\"]\"Respiratory<\/a> Figure 2.2 Respiratory system[\/caption]\r\n\r\nA focused respiratory system assessment includes collecting subjective data about the patient's history of smoking, collecting the patient's and patient's family's history of pulmonary disease, and asking the patient about any\u00a0signs and symptoms of pulmonary disease, such as cough and shortness of breath. Objective data is also assessed.\r\n\r\nThe focused respiratory system assessment in Checklist 19\u00a0outlines the process for gathering objective data.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
<\/a>Checklist 19: Focused Respiratory\u00a0System Assessment<\/caption>\r\n
\r\n
Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n
\r\n
Safety considerations:<\/h5>\r\n
\r\n

Steps<\/h4>\r\n<\/td>\r\n

\r\n

Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

1. Conduct a focused interview\u00a0related to history of respiratory disease, smoking, and environmental exposures.<\/td>\r\nAsk relevant questions related to dyspnea, cough\/sputum, fever, chills, chest pain with breathing, previous history, treatment, medications, etc.<\/td>\r\n<\/tr>\r\n
2.\u00a0Inspect:<\/span>\r\n
    \r\n \t
  • For use of accessory muscles and work of breathing<\/span><\/li>\r\n \t
  • Configuration and symmetry of the chest<\/span><\/li>\r\n \t
  • Respirations for rate (1\u00a0minute), depth, rhythm pattern<\/span><\/li>\r\n \t
  • Skin colour of lips, face, hands, feet<\/span><\/li>\r\n \t
  • O2<\/sub> saturation with a pulse oximeter<\/span><\/li>\r\n<\/ul>\r\n<\/td>\r\n
Patients in respiratory distress may have an anxious expression, pursed lips, and\/or nasal flaring.\r\n\r\nAsymmetrical chest expansion may indicate conditions such as pneumothorax, rib fracture, severe pneumonia, or atelectasis.\r\n\r\n[caption id=\"attachment_6410\" align=\"aligncenter\" width=\"300\"]\"assess<\/a> Assess respiration rate[\/caption]\r\n\r\nWith hypoxemia, cyanosis of the extremities or around the mouth may be noted.<\/td>\r\n<\/tr>\r\n
3.\u00a0Auscultate (anterior and posterior) lungs for breath sounds and adventitious sounds.<\/span><\/span>\r\n\r\n <\/td>\r\nFine crackles (rales) may indicate\u00a0asthma and chronic obstructive pulmonary disease (COPD).\r\n\r\nCoarse crackles\u00a0may indicate pulmonary edema.\r\n\r\nWheezing may indicate asthma, bronchitis, or emphysema.\r\n\r\nLow-pitched wheezing (rhonchi) may indicate pneumonia.\r\n\r\nPleural friction rub (creaking) may indicate pleurisy.\r\n\r\n[caption id=\"attachment_6777\" align=\"aligncenter\" width=\"300\"]\"Auscultate<\/a> Auscultate anterior chest; blue dots indicate stethoscope placement for auscultation[\/caption]\r\n\r\n[caption id=\"attachment_6780\" align=\"aligncenter\" width=\"300\"]\"Auscultate<\/a> Auscultate posterior chest; blue dots indicate stethoscope placement for auscultation[\/caption]<\/td>\r\n<\/tr>\r\n
4. Report and document assessment findings and related health problems according to agency policy.<\/td>\r\nAccurate and timely documentation and reporting promote patient safety.<\/td>\r\n<\/tr>\r\n
Data source:\u00a0Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n

<\/a>Focused Cardiovascular and Peripheral Vascular System Assessment<\/h2>\r\n[caption id=\"attachment_6534\" align=\"aligncenter\" width=\"500\"]\"\"<\/a> Figure 2.3 Anatomy of the heart[\/caption]\r\n\r\nThe cardiovascular and peripheral vascular system affects the entire body. A\u00a0cardiovascular and peripheral vascular system assessment includes collecting subjective data about the patient's diet, nutrition, exercise, and stress levels; collecting the patient's and the patient's family's history of cardiovascular\u00a0disease; and asking the patient about any\u00a0signs and symptoms of cardiovascular and peripheral vascular disease, such as\u00a0peripheral edema, shortness of breath (dyspnea), and irregular pulse rate. Objective data is also assessed.\r\n\r\nThe focused cardiovascular and peripheral vascular system assessment in Checklist 20\u00a0outlines the process for gathering objective data.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
<\/a>Checklist 20: Focused Cardiovascular\/Peripheral Vascular System Assessment<\/caption>\r\n
\r\n
Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n
\r\n
Safety considerations:\u00a0<\/span><\/h5>\r\n
\r\n

Steps<\/h4>\r\n<\/td>\r\n

\r\n

\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

1. Conduct a focused interview\u00a0related to cardiovascular and peripheral vascular disease.<\/td>\r\nAsk relevant questions related to\u00a0chest pain\/shortness of breath (dyspnea), edema, cough, fatigue, cardiac risk factors, leg pain, skin changes, swelling in limbs, history of past illnesses, history of diabetes, injury.<\/td>\r\n<\/tr>\r\n
2. Inspect:\r\n
    \r\n \t
  • Face, lips, and ears for cyanosis<\/li>\r\n \t
  • Chest for deformities, scars<\/li>\r\n \t
  • Bilateral arms\/hands, noting\u00a0CWMS, edema, colour of nail beds, and capillary refill<\/li>\r\n \t
  • Bilateral legs, noting\u00a0CWMS, edema to lower legs and feet, presence of superficial distended veins, colour\u00a0of nail beds, and capillary refill<\/li>\r\n \t
  • calf size\/pain for signs of DVT<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Cyanosis is an indication of decreased perfusion\u00a0and oxygenation.\r\n\r\n[caption id=\"attachment_6441\" align=\"aligncenter\" width=\"300\"]\"Assess<\/a> Assess capillary refill[\/caption]\r\n\r\n[caption id=\"attachment_6415\" align=\"aligncenter\" width=\"300\"]\"Assess<\/a> Assess bilateral lower legs[\/caption]\r\n\r\nAlterations and bilateral inconsistencies in colour, warmth, movement, and sensation (CWMS) may indicate underlying conditions or injury.\r\n\r\nSudden onset of intense, sharp muscle pain that increases with dorsiflexion of foot is an indication of deep venous thrombosis (DVT)<\/strong>, as is increased warmth, redness, tenderness, and swelling in the calf.\r\n\r\nNote:<\/strong>\u00a0DVT requires\u00a0emergency referral because of the risk of developing a pulmonary embolism.<\/span><\/td>\r\n<\/tr>\r\n
3. Auscultate apical pulse for one\u00a0minute. N<\/span>ote the rate and rhythm.<\/td>\r\nNote the heart rate and rhythm. Identify S1 and S2 and follow up on any unusual\u00a0findings.\r\n\r\n[caption id=\"attachment_6778\" align=\"aligncenter\" width=\"300\"]\"Auscultate<\/a> Auscultate apical pulse at the fifth intercostal space and midclavicular line[\/caption]<\/td>\r\n<\/tr>\r\n
4. Palpate the radial, brachial, dorsalis pedis, and posterior tibialis pulses.<\/td>\r\nAbsence of pulse may indicate vessel constriction, possibly due to surgical procedures, injury, or obstruction.\r\n\r\n[caption id=\"attachment_6443\" align=\"aligncenter\" width=\"300\"]\"Assess<\/a> Assess tibial pulses[\/caption]\r\n\r\n[caption id=\"attachment_6442\" align=\"aligncenter\" width=\"300\"]\"Assess<\/a> Assess pedal pulses[\/caption]<\/td>\r\n<\/tr>\r\n
5. Report and document assessment findings and related health problems according to agency policy.<\/td>\r\nAccurate and timely documentation and reporting promote patient safety.<\/td>\r\n<\/tr>\r\n
Data source:\u00a0Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n

<\/a>Focused Gastrointestinal and Genitourinary Assessment<\/h2>\r\n[caption id=\"attachment_6699\" align=\"aligncenter\" width=\"423\"]\"\"<\/a> Figure 2.4 Gastrointestinal system[\/caption]\r\n\r\n[caption id=\"attachment_6678\" align=\"aligncenter\" width=\"356\"]\"\"<\/a> Figure 2.5 Components of the urinary system[\/caption]\r\n\r\nThe 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\u00a0assessment includes collecting subjective data about the patient's diet and exercise levels, collecting the patient's and the patient's family's history of gastrointestinal and genitourinary\u00a0disease, and\u00a0asking the patient about any signs and symptoms of gastrointestinal and genitourinary\u00a0disease, such as abdominal pain, nausea, vomiting, bloating, constipation, diarrhea, and characteristics of urine and faeces. Objective data is also assessed.\r\n\r\nThe focused gastrointestinal and genitourinary\u00a0assessment in Checklist 21 outlines the process for gathering objective data.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
<\/a>Checklist 21: Focused Gastrointestinal and Genitourinary Assessment<\/caption>\r\n
\r\n
Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n
\r\n
Safety considerations:\u00a0<\/span><\/h5>\r\n
\r\n

\u00a0Position patient supine if tolerated<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Steps<\/h4>\r\n<\/td>\r\n

\r\n

\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

1. Conduct a focused interview related to\u00a0gastrointestinal and genitourinary systems.<\/span><\/td>\r\nAsk relevant questions related to the abdomen,\u00a0urine output, last bowel movement,\u00a0flatus, any changes, diet, nausea, vomiting, diarrhea.<\/span><\/td>\r\n<\/tr>\r\n
2. Inspect:<\/span>\r\n
    \r\n \t
  • Abdomen for distension, striae, scars, contour, and symmetry<\/span><\/li>\r\n \t
  • Observe any abdominal movements associated with respiration, or any pulsations or peristaltic waves<\/span><\/li>\r\n<\/ul>\r\n<\/td>\r\n
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.<\/span>\r\n\r\n\u00a0<\/span><\/td>\r\n<\/tr>\r\n
3. Auscultate a<\/span>bdomen for bowel sounds in all four quadrants before palpation.<\/span><\/td>\r\nHyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileus.<\/span>\r\n\r\nHypoactive or absent bowel sounds may be present after abdominal surgery, or with peritonitis or paralytic ileus.<\/span>\r\n\r\n[caption id=\"attachment_6424\" align=\"aligncenter\" width=\"300\"]\"Auscultate<\/a> Auscultate abdomen for bowel sounds in all four quadrants[\/caption]<\/td>\r\n<\/tr>\r\n
4. Palpate\u00a0abdomen lightly\u00a0<\/em>in all four quadrants.<\/span><\/td>\r\nPalpate to detect presence of masses and distension of bowel and bladder.<\/span>\r\n\r\n[caption id=\"attachment_6422\" align=\"aligncenter\" width=\"300\"]\"Palpate Palpate abdomen lightly in all four quadrants[\/caption]\r\n\r\nPain and tenderness may indicate underlying inflammatory conditions such as peritonitis.<\/span><\/td>\r\n<\/tr>\r\n
Note:<\/strong> If patient is wearing a brief, ensure it is clean and dry. Inspect skin underneath for signs of redness\/rash\/breakdown.<\/span><\/td>\r\n<\/tr>\r\n
Note:<\/strong> If patient has a Foley catheter, inspect bag for urine amount, colour, and clarity. Inspect skin at insertion site for redness\/breakdown.<\/span><\/td>\r\n<\/tr>\r\n
5. Report and document assessment findings and related health problems according to agency policy.\r\n<\/span><\/td>\r\nAccurate and timely documentation and reporting promote patient safety.<\/td>\r\n<\/tr>\r\n
Data source:\u00a0Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n

Focused Musculoskeletal System Assessment<\/h2>\r\n[caption id=\"attachment_10118\" align=\"aligncenter\" width=\"622\"]\"\"<\/a> Figure 2.6a Anterior view of muscles[\/caption]\r\n\r\n[caption id=\"attachment_10117\" align=\"aligncenter\" width=\"608\"]\"\"<\/a> Figure 2.6b Posterior view of muscles[\/caption]\r\n\r\nA focused musculoskeletal\u00a0assessment includes collecting subjective data about the patient's mobility and exercise level,\u00a0collecting\u00a0the patient's and the patient's family's history of musculoskeletal conditions, and asking the patient about any signs and symptoms of\u00a0musculoskeletal\u00a0injury or conditions. Objective data is also assessed.\r\n\r\nThe focused musculoskeletal\u00a0assessment in Checklist 22 outlines the process for gathering objective data.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
<\/a>Checklist 22: Focused Musculoskeletal System Assessment<\/caption>\r\n
\r\n
Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n
\r\n
Safety considerations:\u00a0<\/span><\/h5>\r\n
\r\n

Steps<\/h4>\r\n<\/td>\r\n

\r\n

\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

1. Check patient information prior to assessment:\r\n
    \r\n \t
  • Activity order<\/li>\r\n \t
  • Mobility status<\/li>\r\n \t
  • Falls risk<\/li>\r\n \t
  • Need for assistive devices<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Determine patient's activity as tolerated (AAT)\/bed rest requirements.\r\n\r\n[caption id=\"attachment_6132\" align=\"aligncenter\" width=\"174\"]\"Patient<\/a> Patient position prior to standing[\/caption]\r\n\r\nDetermine if patient has non-weight-bearing, partial, or full weight-bearing status.\r\n\r\nDetermine if patient ambulates independently, with one-person assist (PA), two-person assist (2PA), standby, or lift transfer.\r\n\r\nCheck alertness, medications, pain.\r\n\r\nAsk if patient uses walker\/cane\/wheelchair\/crutches.\r\n\r\nConsider non-slip socks\/hip protectors\/bed-chair alarm.<\/td>\r\n<\/tr>\r\n
2. Conduct a focused interview\u00a0related to mobility and musculoskeletal system.<\/td>\r\nAsk relevant questions related to the musculoskeletal system, including pain, function, mobility, and activity level (e.g.,\u00a0arthritis, joint problems, medications, etc.).<\/td>\r\n<\/tr>\r\n
3. Inspect, palpate, and test muscle strength and range of motion:\r\n
    \r\n \t
  • Bilateral handgrip strength<\/li>\r\n \t
  • Range of motion (ROM) of knees<\/li>\r\n \t
  • Dorsi\/plantar flexion<\/li>\r\n<\/ul>\r\nEvaluate client\u2019s ability to sit up before standing, and to stand before walking, and then assess walking ability.<\/td>\r\n
Note strength of handgrip and foot strength for equality bilaterally.\r\n\r\n[caption id=\"attachment_6413\" align=\"aligncenter\" width=\"300\"]\"\"<\/a> Assess strength on plantarflexion[\/caption]\r\n\r\n[caption id=\"attachment_6442\" align=\"aligncenter\" width=\"300\"]\"Assess<\/a> Assess strength on dorsiflexion[\/caption]\r\n\r\n[caption id=\"attachment_6426\" align=\"aligncenter\" width=\"300\"]\"Assess<\/a> Assess grip strength[\/caption]\r\n\r\nNote patient's\u00a0gait, balance, and presence of pain.<\/td>\r\n<\/tr>\r\n
4. Report and document assessment findings and related health problems according to agency policy.<\/td>\r\nAccurate and timely documentation and reporting promote patient safety.<\/td>\r\n<\/tr>\r\n
Data source:\u00a0Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n

<\/a>Video 2.1<\/h3>\r\n
Watch the video Assessing Range of Motion and Strength<\/em><\/a> by\u00a0Ren\u00e9e Anderson & Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\r\n

<\/a>Focused Neurological System Assessment<\/h2>\r\n[caption id=\"attachment_6714\" align=\"aligncenter\" width=\"512\"]\"\"<\/a> Figure 2.7 Nervous system[\/caption]\r\n\r\nThe neurological system is responsible for all human function. It exerts unconscious control over basic body functions, and it also enables complex interactions with others and the environment (Stephen et al., 2012). A focused neurological\u00a0assessment includes collecting subjective data about the patient's history of head injury or dysfunction, collecting the patient's and the patient's family's history of neurological\u00a0disease, and asking the patient about signs and symptoms of neurological conditions, such as\u00a0seizures, memory loss (amnesia), and visual disturbances. Objective data is also assessed.\r\n\r\nThe focused neurological assessment in Checklist 23 outlines the process for gathering objective data.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
<\/a>Checklist 23: Focused Neurological System Assessment<\/caption>\r\n
\r\n
Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n
\r\n
Safety considerations:\u00a0<\/span><\/h5>\r\n
\r\n

Steps<\/span><\/h4>\r\n<\/td>\r\n

\r\n

\u00a0Additional Information<\/span><\/h4>\r\n<\/td>\r\n<\/tr>\r\n

1. Conduct a focused interview\u00a0related to the neurological system.<\/td>\r\nAsk relevant questions related to past or recent 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.\r\n\r\n[caption id=\"attachment_6427\" align=\"aligncenter\" width=\"300\"]\"Focused<\/a> Focused interview[\/caption]<\/td>\r\n<\/tr>\r\n
2. Assess mental health status.<\/td>\r\nAssess mental status by 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)<\/a>.<\/td>\r\n<\/tr>\r\n
3. Assess neurological function using the Glasgow Coma Scale (GCS):\r\n
    \r\n \t
  • Assess best eye-opening response.<\/li>\r\n \t
  • Assess best motor response.<\/li>\r\n \t
  • Assess best verbal response.<\/li>\r\n<\/ul>\r\n<\/td>\r\n
\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
Best eye-opening response<\/strong>\r\n\r\nRecord \"C\" if eyes closed due to swelling.<\/td>\r\nSpontaneously<\/td>\r\n4<\/td>\r\n<\/tr>\r\n
To speech<\/td>\r\n3<\/td>\r\n<\/tr>\r\n
To pain<\/td>\r\n2<\/td>\r\n<\/tr>\r\n
No response<\/td>\r\n1<\/td>\r\n<\/tr>\r\n
Best motor response (to painful stimuli)<\/strong>\r\nPress at fingernail bed and record best upper-limb response.<\/td>\r\nObeys verbal command<\/td>\r\n6<\/td>\r\n<\/tr>\r\n
Localizes pain<\/td>\r\n5<\/td>\r\n<\/tr>\r\n
Flexion - withdrawal<\/td>\r\n4<\/td>\r\n<\/tr>\r\n
Flexion - abnormal<\/td>\r\n3<\/td>\r\n<\/tr>\r\n
Extension - abnormal<\/td>\r\n2<\/td>\r\n<\/tr>\r\n
No response<\/td>\r\n1<\/td>\r\n<\/tr>\r\n
Best verbal response<\/strong>\r\nRecord \"E\" if endotracheal tube is in place, and\u00a0\"T\" if tracheostomy is in place.<\/td>\r\nOriented x 3 (to person, time, and place)<\/td>\r\n5<\/td>\r\n<\/tr>\r\n
Conversation - confused<\/td>\r\n4<\/td>\r\n<\/tr>\r\n
Speech - inappropriate<\/td>\r\n3<\/td>\r\n<\/tr>\r\n
Sounds - incomprehensible<\/td>\r\n2<\/td>\r\n<\/tr>\r\n
No response<\/td>\r\n1<\/td>\r\n<\/tr>\r\n
Glasgow Coma Scale adapted from Jarvis et al., 2014, p. 699.<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/td>\r\n<\/tr>\r\n
4. Note patient\u2019s LOC (level of consciousness, oriented x 3), general appearance, and behaviour.<\/td>\r\nNote hygiene, grooming, speech patterns, facial expressions.<\/td>\r\n<\/tr>\r\n
5. Assess pupils\u00a0for size, equality, reaction to light (PERL), and consensual reaction to light.<\/td>\r\nUnequal pupils may indicate underlying neurological disease or injury.\r\n\r\n[caption id=\"attachment_6782\" align=\"aligncenter\" width=\"300\"]\"Assess<\/a> Assess pupillary reaction to light[\/caption]<\/td>\r\n<\/tr>\r\n
6. Assess motor strength and sensation.\r\n
    \r\n \t
  • Arms and legs for strength\u00a0(compare bilaterally)<\/li>\r\n \t
  • Handgrips, drift<\/li>\r\n \t
  • Extremities for sensation, numbness, tingling<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Unequal motor\u00a0strength and unusual sensation may indicate underlying neurological disease or injury, such as stroke or head injury.\r\n\r\n[caption id=\"attachment_6439\" align=\"aligncenter\" width=\"300\"]\"Assess<\/a> Assess motor strength and sensation of extremities[\/caption]\r\n\r\n[caption id=\"attachment_6426\" align=\"aligncenter\" width=\"300\"]\"Assess<\/a> Assess motor strength and sensation of extremities[\/caption]\r\n\r\n[caption id=\"attachment_6415\" align=\"aligncenter\" width=\"300\"]\"Assess<\/a> Assess motor strength and sensation of extremities[\/caption]<\/td>\r\n<\/tr>\r\n
7. Report and document assessment findings and related health problems according to agency policy.<\/td>\r\nAccurate and timely documentation and reporting promote patient safety.<\/td>\r\n<\/tr>\r\n
Data source:\u00a0Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n

<\/a>Video 2.2<\/h3>\r\n
Watch the video Neurological Assessment (Basic)<\/a>\u00a0<\/em>by Ren\u00e9e Anderson & Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\r\n
\r\n

Critical Thinking Exercises<\/p>\r\n\r\n<\/header>\r\n

\r\n
    \r\n \t
  1. Your patient complains of stomach pain during your head-to-toe assessment. What would be your next steps?<\/li>\r\n \t
  2. You notice that your patient seems lethargic during your head-to-toe assessment. What would be your next steps?<\/li>\r\n<\/ol>\r\n<\/div>\r\n<\/div>\r\n

    Attributions<\/h2>\r\nFigure 2.2<\/strong>\r\nThe respiratory system<\/a> by LadyofHats<\/a> is in the public domain<\/a>.\r\n\r\nFigure 2.3<\/strong>\r\nSectional anatomy of the heart<\/a> by Blausen Medical Communications, Inc.<\/a> is used under a CC BY 3.0<\/a> licence.\r\n\r\nFigure 2.4<\/strong>\r\nDigestive system diagram<\/a> by Mariana Ruiz Villarreal is in the public domain<\/a>.\r\n\r\nFigure 2.5<\/strong>\r\nUrinary system<\/a> is in the public domain<\/a>.\r\n\r\nFigure 2.6<\/strong>\r\nAnterior and posterior views of muscles<\/a> by OpenStax College is used under a CC BY 3.0<\/a> licence.\r\n\r\nFigure 2.7<\/strong>\r\nNervous system diagram<\/a> by William Crochot is used under a CC BY SA 4.0<\/a> licence.","rendered":"

    Health care professionals do focused assessments in response to a specific patient health problem recognized by the assessor as needing\u00a0further assessment\u00a0of a body system or systems.<\/p>\n

    Focused Respiratory System Assessment<\/h2>\n
    \"Respiratory<\/a>
    Figure 2.2 Respiratory system<\/figcaption><\/figure>\n

    A focused respiratory system assessment includes collecting subjective data about the patient’s history of smoking, collecting the patient’s and patient’s family’s history of pulmonary disease, and asking the patient about any\u00a0signs and symptoms of pulmonary disease, such as cough and shortness of breath. Objective data is also assessed.<\/p>\n

    The focused respiratory system assessment in Checklist 19\u00a0outlines the process for gathering objective data.<\/p>\n\n\n\n\n\n\n\n\n\n\n
    <\/a>Checklist 19: Focused Respiratory\u00a0System Assessment<\/caption>\n
    \n
    Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n
    \n
    Safety considerations:<\/h5>\n
    \n

    Steps<\/h4>\n<\/td>\n

    		\n

    Additional Information<\/h4>\n<\/td>\n<\/tr>\n

    1. Conduct a focused interview\u00a0related to history of respiratory disease, smoking, and environmental exposures.<\/td>\nAsk relevant questions related to dyspnea, cough\/sputum, fever, chills, chest pain with breathing, previous history, treatment, medications, etc.<\/td>\n<\/tr>\n
    2.\u00a0Inspect:<\/span><\/p>\n
      \n
    • For use of accessory muscles and work of breathing<\/span><\/li>\n
    • Configuration and symmetry of the chest<\/span><\/li>\n
    • Respirations for rate (1\u00a0minute), depth, rhythm pattern<\/span><\/li>\n
    • Skin colour of lips, face, hands, feet<\/span><\/li>\n
    • O2<\/sub> saturation with a pulse oximeter<\/span><\/li>\n<\/ul>\n<\/td>\n
    		Patients in respiratory distress may have an anxious expression, pursed lips, and\/or nasal flaring.<\/p>\n

    Asymmetrical chest expansion may indicate conditions such as pneumothorax, rib fracture, severe pneumonia, or atelectasis.<\/p>\n

    \"assess<\/a>
    Assess respiration rate<\/figcaption><\/figure>\n

    With hypoxemia, cyanosis of the extremities or around the mouth may be noted.<\/td>\n<\/tr>\n

    3.\u00a0Auscultate (anterior and posterior) lungs for breath sounds and adventitious sounds.<\/span><\/span><\/p>\n

     <\/td>\n

    		Fine crackles (rales) may indicate\u00a0asthma and chronic obstructive pulmonary disease (COPD).<\/p>\n

    Coarse crackles\u00a0may indicate pulmonary edema.<\/p>\n

    Wheezing may indicate asthma, bronchitis, or emphysema.<\/p>\n

    Low-pitched wheezing (rhonchi) may indicate pneumonia.<\/p>\n

    Pleural friction rub (creaking) may indicate pleurisy.<\/p>\n

    \"Auscultate<\/a>
    Auscultate anterior chest; blue dots indicate stethoscope placement for auscultation<\/figcaption><\/figure>\n
    \"Auscultate<\/a>
    Auscultate posterior chest; blue dots indicate stethoscope placement for auscultation<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    4. Report and document assessment findings and related health problems according to agency policy.<\/td>\nAccurate and timely documentation and reporting promote patient safety.<\/td>\n<\/tr>\n
    Data source:\u00a0Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    <\/a>Focused Cardiovascular and Peripheral Vascular System Assessment<\/h2>\n
    \"\"<\/a>
    Figure 2.3 Anatomy of the heart<\/figcaption><\/figure>\n

    The cardiovascular and peripheral vascular system affects the entire body. A\u00a0cardiovascular and peripheral vascular system assessment includes collecting subjective data about the patient’s diet, nutrition, exercise, and stress levels; collecting the patient’s and the patient’s family’s history of cardiovascular\u00a0disease; and asking the patient about any\u00a0signs and symptoms of cardiovascular and peripheral vascular disease, such as\u00a0peripheral edema, shortness of breath (dyspnea), and irregular pulse rate. Objective data is also assessed.<\/p>\n

    The focused cardiovascular and peripheral vascular system assessment in Checklist 20\u00a0outlines the process for gathering objective data.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n
    <\/a>Checklist 20: Focused Cardiovascular\/Peripheral Vascular System Assessment<\/caption>\n
    \n
    Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n
    \n
    Safety considerations:\u00a0<\/span><\/h5>\n
    \n

    Steps<\/h4>\n<\/td>\n

    		\n

    \u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n

    1. Conduct a focused interview\u00a0related to cardiovascular and peripheral vascular disease.<\/td>\nAsk relevant questions related to\u00a0chest pain\/shortness of breath (dyspnea), edema, cough, fatigue, cardiac risk factors, leg pain, skin changes, swelling in limbs, history of past illnesses, history of diabetes, injury.<\/td>\n<\/tr>\n
    2. Inspect:<\/p>\n
      \n
    • Face, lips, and ears for cyanosis<\/li>\n
    • Chest for deformities, scars<\/li>\n
    • Bilateral arms\/hands, noting\u00a0CWMS, edema, colour of nail beds, and capillary refill<\/li>\n
    • Bilateral legs, noting\u00a0CWMS, edema to lower legs and feet, presence of superficial distended veins, colour\u00a0of nail beds, and capillary refill<\/li>\n
    • calf size\/pain for signs of DVT<\/li>\n<\/ul>\n<\/td>\n
    		Cyanosis is an indication of decreased perfusion\u00a0and oxygenation.<\/p>\n
    \"Assess<\/a>
    Assess capillary refill<\/figcaption><\/figure>\n
    \"Assess<\/a>
    Assess bilateral lower legs<\/figcaption><\/figure>\n

    Alterations and bilateral inconsistencies in colour, warmth, movement, and sensation (CWMS) may indicate underlying conditions or injury.<\/p>\n

    Sudden onset of intense, sharp muscle pain that increases with dorsiflexion of foot is an indication of deep venous thrombosis (DVT)<\/strong>, as is increased warmth, redness, tenderness, and swelling in the calf.<\/p>\n

    Note:<\/strong>\u00a0DVT requires\u00a0emergency referral because of the risk of developing a pulmonary embolism.<\/span><\/td>\n<\/tr>\n

    3. Auscultate apical pulse for one\u00a0minute. N<\/span>ote the rate and rhythm.<\/td>\nNote the heart rate and rhythm. Identify S1 and S2 and follow up on any unusual\u00a0findings.<\/p>\n
    \"Auscultate<\/a>
    Auscultate apical pulse at the fifth intercostal space and midclavicular line<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    4. Palpate the radial, brachial, dorsalis pedis, and posterior tibialis pulses.<\/td>\nAbsence of pulse may indicate vessel constriction, possibly due to surgical procedures, injury, or obstruction.<\/p>\n
    \"Assess<\/a>
    Assess tibial pulses<\/figcaption><\/figure>\n
    \"Assess<\/a>
    Assess pedal pulses<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    5. Report and document assessment findings and related health problems according to agency policy.<\/td>\nAccurate and timely documentation and reporting promote patient safety.<\/td>\n<\/tr>\n
    Data source:\u00a0Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    <\/a>Focused Gastrointestinal and Genitourinary Assessment<\/h2>\n
    \"\"<\/a>
    Figure 2.4 Gastrointestinal system<\/figcaption><\/figure>\n
    \"\"<\/a>
    Figure 2.5 Components of the urinary system<\/figcaption><\/figure>\n

    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\u00a0assessment includes collecting subjective data about the patient’s diet and exercise levels, collecting the patient’s and the patient’s family’s history of gastrointestinal and genitourinary\u00a0disease, and\u00a0asking the patient about any signs and symptoms of gastrointestinal and genitourinary\u00a0disease, such as abdominal pain, nausea, vomiting, bloating, constipation, diarrhea, and characteristics of urine and faeces. Objective data is also assessed.<\/p>\n

    The focused gastrointestinal and genitourinary\u00a0assessment in Checklist 21 outlines the process for gathering objective data.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
    <\/a>Checklist 21: Focused Gastrointestinal and Genitourinary Assessment<\/caption>\n
    \n
    Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n
    \n
    Safety considerations:\u00a0<\/span><\/h5>\n
    \n

    \u00a0Position patient supine if tolerated<\/h4>\n<\/td>\n<\/tr>\n

    \n

    Steps<\/h4>\n<\/td>\n

    		\n

    \u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n

    1. Conduct a focused interview related to\u00a0gastrointestinal and genitourinary systems.<\/span><\/td>\nAsk relevant questions related to the abdomen,\u00a0urine output, last bowel movement,\u00a0flatus, any changes, diet, nausea, vomiting, diarrhea.<\/span><\/td>\n<\/tr>\n
    2. Inspect:<\/span><\/p>\n
      \n
    • Abdomen for distension, striae, scars, contour, and symmetry<\/span><\/li>\n
    • Observe any abdominal movements associated with respiration, or any pulsations or peristaltic waves<\/span><\/li>\n<\/ul>\n<\/td>\n
    		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.<\/span><\/p>\n

    \u00a0<\/span><\/td>\n<\/tr>\n

    3. Auscultate a<\/span>bdomen for bowel sounds in all four quadrants before palpation.<\/span><\/td>\nHyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileus.<\/span><\/p>\n

    Hypoactive or absent bowel sounds may be present after abdominal surgery, or with peritonitis or paralytic ileus.<\/span><\/p>\n

    \"Auscultate<\/a>
    Auscultate abdomen for bowel sounds in all four quadrants<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    4. Palpate\u00a0abdomen lightly\u00a0<\/em>in all four quadrants.<\/span><\/td>\nPalpate to detect presence of masses and distension of bowel and bladder.<\/span><\/p>\n
    \"Palpate
    Palpate abdomen lightly in all four quadrants<\/figcaption><\/figure>\n

    Pain and tenderness may indicate underlying inflammatory conditions such as peritonitis.<\/span><\/td>\n<\/tr>\n

    Note:<\/strong> If patient is wearing a brief, ensure it is clean and dry. Inspect skin underneath for signs of redness\/rash\/breakdown.<\/span><\/td>\n<\/tr>\n
    Note:<\/strong> If patient has a Foley catheter, inspect bag for urine amount, colour, and clarity. Inspect skin at insertion site for redness\/breakdown.<\/span><\/td>\n<\/tr>\n
    5. Report and document assessment findings and related health problems according to agency policy.
    \n<\/span><\/td>\n    		Accurate and timely documentation and reporting promote patient safety.<\/td>\n<\/tr>\n
    Data source:\u00a0Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    Focused Musculoskeletal System Assessment<\/h2>\n
    \"\"<\/a>
    Figure 2.6a Anterior view of muscles<\/figcaption><\/figure>\n
    \"\"<\/a>
    Figure 2.6b Posterior view of muscles<\/figcaption><\/figure>\n

    A focused musculoskeletal\u00a0assessment includes collecting subjective data about the patient’s mobility and exercise level,\u00a0collecting\u00a0the patient’s and the patient’s family’s history of musculoskeletal conditions, and asking the patient about any signs and symptoms of\u00a0musculoskeletal\u00a0injury or conditions. Objective data is also assessed.<\/p>\n

    The focused musculoskeletal\u00a0assessment in Checklist 22 outlines the process for gathering objective data.<\/p>\n\n\n\n\n\n\n\n\n\n\n
    <\/a>Checklist 22: Focused Musculoskeletal System Assessment<\/caption>\n
    \n
    Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n
    \n
    Safety considerations:\u00a0<\/span><\/h5>\n
    \n

    Steps<\/h4>\n<\/td>\n

    		\n

    \u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n

    1. Check patient information prior to assessment:<\/p>\n
      \n
    • Activity order<\/li>\n
    • Mobility status<\/li>\n
    • Falls risk<\/li>\n
    • Need for assistive devices<\/li>\n<\/ul>\n<\/td>\n
    		Determine patient’s activity as tolerated (AAT)\/bed rest requirements.<\/p>\n
    \"Patient<\/a>
    Patient position prior to standing<\/figcaption><\/figure>\n

    Determine if patient has non-weight-bearing, partial, or full weight-bearing status.<\/p>\n

    Determine if patient ambulates independently, with one-person assist (PA), two-person assist (2PA), standby, or lift transfer.<\/p>\n

    Check alertness, medications, pain.<\/p>\n

    Ask if patient uses walker\/cane\/wheelchair\/crutches.<\/p>\n

    Consider non-slip socks\/hip protectors\/bed-chair alarm.<\/td>\n<\/tr>\n

    2. Conduct a focused interview\u00a0related to mobility and musculoskeletal system.<\/td>\nAsk relevant questions related to the musculoskeletal system, including pain, function, mobility, and activity level (e.g.,\u00a0arthritis, joint problems, medications, etc.).<\/td>\n<\/tr>\n
    3. Inspect, palpate, and test muscle strength and range of motion:<\/p>\n
      \n
    • Bilateral handgrip strength<\/li>\n
    • Range of motion (ROM) of knees<\/li>\n
    • Dorsi\/plantar flexion<\/li>\n<\/ul>\n

      Evaluate client\u2019s ability to sit up before standing, and to stand before walking, and then assess walking ability.<\/td>\n

    		Note strength of handgrip and foot strength for equality bilaterally.<\/p>\n
    \"\"<\/a>
    Assess strength on plantarflexion<\/figcaption><\/figure>\n
    \"Assess<\/a>
    Assess strength on dorsiflexion<\/figcaption><\/figure>\n
    \"Assess<\/a>
    Assess grip strength<\/figcaption><\/figure>\n

    Note patient’s\u00a0gait, balance, and presence of pain.<\/td>\n<\/tr>\n

    4. Report and document assessment findings and related health problems according to agency policy.<\/td>\nAccurate and timely documentation and reporting promote patient safety.<\/td>\n<\/tr>\n
    Data source:\u00a0Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    <\/a>Video 2.1<\/h3>\n
    Watch the video Assessing Range of Motion and Strength<\/em><\/a> by\u00a0Ren\u00e9e Anderson & Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\n

    <\/a>Focused Neurological System Assessment<\/h2>\n
    \"\"<\/a>
    Figure 2.7 Nervous system<\/figcaption><\/figure>\n

    The neurological system is responsible for all human function. It exerts unconscious control over basic body functions, and it also enables complex interactions with others and the environment (Stephen et al., 2012). A focused neurological\u00a0assessment includes collecting subjective data about the patient’s history of head injury or dysfunction, collecting the patient’s and the patient’s family’s history of neurological\u00a0disease, and asking the patient about signs and symptoms of neurological conditions, such as\u00a0seizures, memory loss (amnesia), and visual disturbances. Objective data is also assessed.<\/p>\n

    The focused neurological assessment in Checklist 23 outlines the process for gathering objective data.<\/p>\n\n\n\n\n\n\n\n\n
    <\/a>Checklist 23: Focused Neurological System Assessment<\/caption>\n
    \n
    Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n
    \n
    Safety considerations:\u00a0<\/span><\/h5>\n
    \n

    Steps<\/span><\/h4>\n<\/td>\n

    		\n

    \u00a0Additional Information<\/span><\/h4>\n<\/td>\n<\/tr>\n

    1. Conduct a focused interview\u00a0related to the neurological system.<\/td>\nAsk relevant questions related to past or recent 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.<\/p>\n
    \"Focused<\/a>
    Focused interview<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    2. Assess mental health status.<\/td>\nAssess mental status by 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)<\/a>.<\/td>\n<\/tr>\n
    3. Assess neurological function using the Glasgow Coma Scale (GCS):<\/p>\n
      \n
    • Assess best eye-opening response.<\/li>\n
    • Assess best motor response.<\/li>\n
    • Assess best verbal response.<\/li>\n<\/ul>\n<\/td>\n
    		\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
    Best eye-opening response<\/strong><\/p>\n

    Record “C” if eyes closed due to swelling.<\/td>\n

    		Spontaneously<\/td>\n4<\/td>\n<\/tr>\n
    To speech<\/td>\n3<\/td>\n<\/tr>\n
    To pain<\/td>\n2<\/td>\n<\/tr>\n
    No response<\/td>\n1<\/td>\n<\/tr>\n
    Best motor response (to painful stimuli)<\/strong>
    \nPress at fingernail bed and record best upper-limb response.<\/td>\n    		Obeys verbal command<\/td>\n6<\/td>\n<\/tr>\n
    Localizes pain<\/td>\n5<\/td>\n<\/tr>\n
    Flexion – withdrawal<\/td>\n4<\/td>\n<\/tr>\n
    Flexion – abnormal<\/td>\n3<\/td>\n<\/tr>\n
    Extension – abnormal<\/td>\n2<\/td>\n<\/tr>\n
    No response<\/td>\n1<\/td>\n<\/tr>\n
    Best verbal response<\/strong>
    \nRecord “E” if endotracheal tube is in place, and\u00a0“T” if tracheostomy is in place.<\/td>\n    		Oriented x 3 (to person, time, and place)<\/td>\n5<\/td>\n<\/tr>\n
    Conversation – confused<\/td>\n4<\/td>\n<\/tr>\n
    Speech – inappropriate<\/td>\n3<\/td>\n<\/tr>\n
    Sounds – incomprehensible<\/td>\n2<\/td>\n<\/tr>\n
    No response<\/td>\n1<\/td>\n<\/tr>\n
    Glasgow Coma Scale adapted from Jarvis et al., 2014, p. 699.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n
    4. Note patient\u2019s LOC (level of consciousness, oriented x 3), general appearance, and behaviour.<\/td>\nNote hygiene, grooming, speech patterns, facial expressions.<\/td>\n<\/tr>\n
    5. Assess pupils\u00a0for size, equality, reaction to light (PERL), and consensual reaction to light.<\/td>\nUnequal pupils may indicate underlying neurological disease or injury.<\/p>\n
    \"Assess<\/a>
    Assess pupillary reaction to light<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    6. Assess motor strength and sensation.<\/p>\n
      \n
    • Arms and legs for strength\u00a0(compare bilaterally)<\/li>\n
    • Handgrips, drift<\/li>\n
    • Extremities for sensation, numbness, tingling<\/li>\n<\/ul>\n<\/td>\n
    		Unequal motor\u00a0strength and unusual sensation may indicate underlying neurological disease or injury, such as stroke or head injury.<\/p>\n
    \"Assess<\/a>
    Assess motor strength and sensation of extremities<\/figcaption><\/figure>\n
    \"Assess<\/a>
    Assess motor strength and sensation of extremities<\/figcaption><\/figure>\n
    \"Assess<\/a>
    Assess motor strength and sensation of extremities<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    7. Report and document assessment findings and related health problems according to agency policy.<\/td>\nAccurate and timely documentation and reporting promote patient safety.<\/td>\n<\/tr>\n
    Data source:\u00a0Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    <\/a>Video 2.2<\/h3>\n
    Watch the video Neurological Assessment (Basic)<\/a>\u00a0<\/em>by Ren\u00e9e Anderson & Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\n
    \n
    \n

    Critical Thinking Exercises<\/p>\n<\/header>\n

    \n
      \n
    1. Your patient complains of stomach pain during your head-to-toe assessment. What would be your next steps?<\/li>\n
    2. You notice that your patient seems lethargic during your head-to-toe assessment. What would be your next steps?<\/li>\n<\/ol>\n<\/div>\n<\/div>\n

      Attributions<\/h2>\n

      Figure 2.2<\/strong>
      \n      The respiratory system<\/a> by LadyofHats<\/a> is in the public domain<\/a>.<\/p>\n

      Figure 2.3<\/strong>
      \n      Sectional anatomy of the heart<\/a> by Blausen Medical Communications, Inc.<\/a> is used under a CC BY 3.0<\/a> licence.<\/p>\n

      Figure 2.4<\/strong>
      \n      Digestive system diagram<\/a> by Mariana Ruiz Villarreal is in the public domain<\/a>.<\/p>\n

      Figure 2.5<\/strong>
      \n      Urinary system<\/a> is in the public domain<\/a>.<\/p>\n

      Figure 2.6<\/strong>
      \n      Anterior and posterior views of muscles<\/a> by OpenStax College is used under a CC BY 3.0<\/a> licence.<\/p>\n

      Figure 2.7<\/strong>
      \n      Nervous system diagram<\/a> by William Crochot is used under a CC BY SA 4.0<\/a> licence.<\/p>\n","protected":false},"author":5,"menu_order":7,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-311","chapter","type-chapter","status-publish","hentry"],"part":253,"_links":{"self":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/311","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/users\/5"}],"version-history":[{"count":30,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/311\/revisions"}],"predecessor-version":[{"id":10224,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/311\/revisions\/10224"}],"part":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/parts\/253"}],"metadata":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/311\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/media?parent=311"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapter-type?post=311"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/contributor?post=311"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/license?post=311"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}