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Focused  System  Assessment  Requirements  for  NURS  311  &  NURS  333    

Intended  for  Students,  Instructors  &  faculty    

*  indicates  need  for  bilateral  assessment    

Environment    
• Suction:  setup  and  function      
• Oxygen:  verifies  presence  of  O2,  Verifies  rate  of  flow  &  device    
• Bed:  lifts  to  safe  working  height,  lowers  when  leaving  room  
• IV:  rate,  solution,  site    
• Foleys/drains:  verifies  presence  
 

Communication    
§ Demonstrate  communication  with  their  patient  and  partner  that  is:  
o Respectful  
o Professional  
o Timely    
o Clear  
§ Recognize  possible  missed  patient  assessments  /  interventions  and  communicate  these  during  
the  scenario    
§ Document  in  an  accurate  and  timely  manner  on  appropriate  forms,  each  lab  
§ Focus  on  patient  priorities  throughout  each  scenario  
§ SBAR:  Detailed,  accurate,  clear      
 

CNS  
• General  appearance  
• Behavior    
• Level  of  consciousness,  GCS  score,  Orientation  X3  
• PERRLA  
• Dizziness,  visual  disturbances,  tremors*  
• Body  position/posture/gait*  
• Pain  or  headache:  PQRSTU  

CVS  
• BP  
• Distal  Pules(s):  rate,  rhythm,  quality  (0,  1+,  2+,  3+)  (radial)*  
• Heart  Sounds:  S1S2,  Apical  pulse  (rate,  rhythm,  quality)  
• Extra  heart  sounds,  murmurs  
• Chest  pain:  PQRSTU  
 
 

(Haase,  Dahl,  Rodger,  Mishak,  Bullin,  &  Bergen,  2015)  


 
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Respiratory    
• Resp  rate,  rhythm,  quality    
• Work  of  breathing  (SOB,  resps  easy,  distress,  orthopnea,  accessory  muscles,  tripod)  
• Oxygen  delivery  type  and  concentration  (also  part  of  enviro  assessment)  
• SaO2%  (Room  air,  02)  
• Auscultation:  air  entry,  adventitious  sounds  (anterior  &  posterior)*  
• Cough:  frequency,  characteristic,  productive?  (sputum?)  
• Pain:  PQRSTU  

PVS  
• Cap  refill  &  peripheral  pulses  (dorsalis  pedis  or  posterior  tibialis  OR  related  pulses)*  
• Color,  warmth,  movement,  sensation  of  all  extremities*  
• Edema-­‐  location,  pitting,  non-­‐pitting*  
• Pain  to  extremities:  PQRSTU  

GI  
• Abdomen  contour  (flat,  round,  protuberant),  soft/firm,  distention  
• Bowel  sounds  x4  (start  in  RLQ)  
• N/V/BM  (frequency,  intensity)    
• Nutritional  status  (eating/drinking,  current  diet?  Tolerating  diet?)  
• Pain  to  abdomen/GI:  PQRSTU  

GU  
• Urine  (amount,  appearance,  odor,  frequency  or  urgency)  
• Presence  of  catheters  or  drainage  
• Pain  to  related  to  voiding/GU:  PQRSTU  

MSK  
• ROM,  Movement  and  strength  of  extremities*  
• Circulation,  sensation,  warmth  of  affected  extremity*      
• Pain  to  extremities:  PQRSTU  

INTEG:    
• General  skin  appearance  (color,  hair  distribution,  redness)    
• Pressure  points    
• Wounds-­‐  assess  using  REEDA/MEASURE  
• Pain  related  to  skin/wounds:  PQRSTU  

(Haase,  Dahl,  Rodger,  Mishak,  Bullin,  &  Bergen,  2015)  


 

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