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Assessment by Body System

Assessment by Body System. An alternate method of assessment. I. Introduction to the Client. 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.

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Assessment by Body System

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  1. Assessment by Body System An alternate method of assessment

  2. I. Introduction to the Client • 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

  3. II. Vital Signs • Temperature • Pulse • Respirations • Blood Pressure • Pain Assessment • Weight/Height • O₂ Saturation

  4. III. Neurological Assessment • Level of Consciousness • Stimulus Response b. Pupils (PERRLA)-examination of clients eyes • Pupils Equal Round Reactive to Light and Accommodation • Means the ability of the eyes to focus on objects that are close up and faraway

  5. IV. Cardiac Assessment • Pulses- Apical, Radial, Pedal Quality & Rate Bilaterally • Capillary Refill • Neck Veins • Edema-check feet, hands, scrotum • Heart Sounds-lub/dub, rhythm, murmurs • Sighs and Symptoms of Shock • Increased heart rate • Decreased blood pressure g. Cool, clammy skin

  6. b. Capillary Refill • Can be done on the fingers or toes • Press down on the nail bed • Color will blanch • Assess the time for the color to return • Capillary refill should return in 3 seconds or less • Delay in capillary refill may indicate impaired circulation

  7. c. Neck Veins • Neck veins should be checked by having patient sit at a 45 degree angle • In this position, the jugular veins should be flat • Distended neck veins at 45 degrees are an indicator of over hydration or fluid overload

  8. Neck Veins Distended Veins Flattened Veins

  9. V. Motor Functioning • Facial Symmetry • Check teeth, raise eyebrows b. Hand grips c. Movements & Strength of Extremities • Patients extends arms, check reflexes

  10. VI. Respiratory Assessment • Inspection of skin color, barrel chest of emphysema • Auscultation • Lung sounds-wales/crackles, wheezes c. Sputum-color consistency d. Cough-productive, non productive e. Oxygen administration and response

  11. VII. Gastrointestinal & Abdominal Assessment • Inspection- flat, round, distended • Auscultation • Bowel sounds; 4 quadrants - hypoactive, active, hyperactive, absent 2. Listen for abdominal aorta bruit • Palpation- pain?, deep to determine liver margins • Percussion- air, fluid? • Nausea, Vomiting, Dyspepsia, Anorexia • Nutrition-intake, pain when eating, appetite • Lab Values-protein, prealbumin(blood test)

  12. VIII. Fluids & Electrolytes • Intake and Output • Peripheral Edema • Diaphoresis (excessive sweating) • I.V. Site • Lab Values- electrolytes

  13. IX. Examination • Color, odor, amount • Last bowel movement color, character and consistency • Excessive sweating e. Blood, Urea, Nitrogen (BUN), Creatinine, blood in Stool? • Urinary Assessment • Stool • Diaphoresis • Drainage form dressing, drains • Lab Values

  14. X. Musculoskeletal Assessment • Muscle Strength • Mobile? Immobile

  15. XI. Endocrine/Regulation • Hearing, vision • Glucose levels, altered levels of consciousness, Feet/skin • Monitor heart rate & blood pressure • Senses • Diabetic • Thyroid

  16. XII. Integumentary System • redness, lesions, skin to muscle & to bone • Intake, likes/dislikes, output • Decubiti (when in lying down position) • Nutrition

  17. XIII. Psychosocial Aspects • Affect of illness on role; such as work, family • Inappropriate independence, dependence? • Check for depression, suicidal ideation of needed

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