Chapter 2. Patient Assessment Show
Health care professionals do focused assessments in response to a specific patient health problem recognized by the assessor as needing further assessment of a body system or systems. Focused Respiratory System AssessmentFigure 2.2 Respiratory systemA 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 signs and symptoms of pulmonary disease, such as cough and shortness of breath. Objective data is also assessed. The focused respiratory system assessment in Checklist 19 outlines the process for gathering objective data. Checklist 19: Focused Respiratory System Assessment
Focused Cardiovascular and Peripheral Vascular System AssessmentFigure 2.3 Anatomy of the heartThe cardiovascular and peripheral vascular system affects the entire body. A cardiovascular 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 disease; and asking the patient about any signs and symptoms of cardiovascular and peripheral vascular disease, such as peripheral edema, shortness of breath (dyspnea), and irregular pulse rate. Objective data is also assessed. The focused cardiovascular and peripheral vascular system assessment in Checklist 20 outlines the process for gathering objective data. Checklist 20: Focused Cardiovascular/Peripheral Vascular System Assessment
Focused Gastrointestinal and Genitourinary AssessmentFigure 2.4 Gastrointestinal systemFigure 2.5 Components of the urinary systemThe 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 assessment 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 disease, and asking the patient about any signs and symptoms of gastrointestinal and genitourinary disease, such as abdominal pain, nausea, vomiting, bloating, constipation, diarrhea, and characteristics of urine and faeces. Objective data is also assessed. The focused gastrointestinal and genitourinary assessment in Checklist 21 outlines the process for gathering objective data. Checklist 21: Focused Gastrointestinal and Genitourinary Assessment
Focused Musculoskeletal System AssessmentFigure 2.6a Anterior view of musclesFigure 2.6b Posterior view of musclesA focused musculoskeletal assessment includes collecting subjective data about the patient’s mobility and exercise level, collecting the patient’s and the patient’s family’s history of musculoskeletal conditions, and asking the patient about any signs and symptoms of musculoskeletal injury or conditions. Objective data is also assessed. The focused musculoskeletal assessment in Checklist 22 outlines the process for gathering objective data. Checklist 22: Focused Musculoskeletal System Assessment
Video 2.1Focused Neurological System AssessmentFigure 2.7 Nervous systemThe 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 assessment 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 disease, and asking the patient about signs and symptoms of neurological conditions, such as seizures, memory loss (amnesia), and visual disturbances. Objective data is also assessed. The focused neurological assessment in Checklist 23 outlines the process for gathering objective data. Checklist 23: Focused Neurological System Assessment
Video 2.2
AttributionsFigure 2.2 Figure 2.3 Figure 2.4 Figure 2.5 Figure 2.6 Figure 2.7 Which question would the nurse ask first to obtain information about the patient's bowel habits?Ask the patient the following questions about bowel habit.
What is the consistency of the bowel movement? Do you have any diarrhea or constipation? Have you had any change in bowel habits? Do you have any problems having a bowel movement?
Which bowel elimination problem is most likely the result of improper diet?Constipation occurs when bowel movements become less frequent and stools become difficult to pass. It happens most often due to changes in diet or routine, or due to inadequate intake of fiber.
Which signs and symptoms are characteristic of constipation select all that apply?The following signs and symptoms characterize constipation:. Infrequent passage of stool- fewer than three bowel movements per week.. Passage of dry, hard stool.. Passage of liquid fecal seepage.. Frequent but non-productive desire to defecate.. Straining at stools.. Pain upon defecation.. Abdominal pain or distention.. Anorexia.. Which characteristic indicates constipation?Constipation is broadly defined as unsatisfactory defecation characterized by infrequent stools, difficult stool passage or both (1).
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