System Specific Assessments (Nursing)

00:01 The topic we are going to cover this time is on reduction of risk potential category and underneath that is system specific assessments. So we are going to talk a little bit about that and before we get started I just want to introduce myself. I am Diana Shenefield and let’s get started. So overview of the content. What are we going to talk about in this section and what we are talking about is system specific assessments. In a lot of time, you'll hear it called focused assessments and we know when we have our patients on the floor that every time we go in to see them we don’t always do it head to toe. But we focused on certain body systems and this is what this lecture is a little bit about. Just to get you thinking about that topic and what NCLEX would be looking for. So as before make sure you read through the learning outcomes. Make sure that you are comfortable with assessment and re-assessment. Make sure that you are looking as specific risk assessments. So we get focusing on a body system and risks and complications that could happen in that body system and being able to recognize changes in your patient.

01:10 So let’s start with a question. We have a child with a diagnosis of meningococcal meningitis and they develop signs of sepsis and purpuric rash over both legs. So as you are taking NCLEX questions a lot of times it helps if you can read the question and picture that patient in front of you. Make that patient real to you so that it will be easier for you to think through the question and the answers. The physicians should be notified immediately because of the following signs. So which of the four answers should the physician be notified immediately if the patient presents with these signs and symptoms.

01:49 A, a severe allergic reaction to the antibiotic with impending anaphylaxis. Now a lot of times students will see anaphylaxis and think that’s the one has to be. Because anaphylaxis is life threatening. But again make sure that your answer is fitting the question and in this question we have a patient with meningococcal meningitis. B, has onset of syndromes of inappropriate antidiuretic hormone, SIADH. We also know that a patient with meningitis could develop SIADH. But is that what the symptoms on that question is telling us. How about C, meningococcemia or D, adhesive arachnoiditis? Again sometimes you know you are looking at answers and you are like “I don’t even know what that is?” Use your medical terminology and make sure you breakdown the word. But again sometimes they'll throw things on that just a kind of throw yet just to see if they can riddle you. Why? Because as nurses we need to be able to keep our heads in critical situations. So looking at these four answers, you got the patient with sepsis and they've got the purple rash. So which one of this answers are you going to pick? Hopefully you pick C, meningococcemia. Again hard word to say but you know what I am talking about. Make sure that you are watching that purple rash. It is so important to watch for. They are going into a sepsis caused by meningococcal. So again don’t get stuck on keywords like anaphylaxis. Make sure your answers fits the question that is being asked.

03:32 There is another question. You have a nurse assessing a patient who just sustained blunt force trauma to the chest from a steering wheel. We know we have patients that come in all the time. They hit the steering wheel. So run through your mind what is blunt force trauma from a steering wheel looks like. Which of these signs would indicate the presence of the pneumothorax? So we have a blunt force trauma and we have pneumothorax. Is it A-, a low respiratory rates? B, diminished breath sounds? C, the presence of a barrel chest or D, a sucking sound at the site of injury? Now again remember a blunt chest wound is not going to have sucking sounds because it's all contained. So you can eliminate that one right away. A low respiratory rate. Think through all your patients that have had trauma to the chest. Their respiratory rate probably is not going to go down. They are going to start breathing faster. And what about the presence of the barrel chest? We know from learning in nursing school, a barrel chest happens over time from chronic respiratory problems.

04:43 So that leaves B diminished breath sounds. So right there in your mind a pneumothorax, what is that? That is one of the lungs has been decompressed. We are going to have the diminished breath sounds. So again make sure you look at the questions.

04:59 Make sure you know exactly what it’s asking you and then pick the answer that fits with the question is asking. So now let’s get back to our system specific assessment. Again most of the time you are going to hear nurses call a focused assessment. You are focusing on the body part that has the illness. But remember, if I have a patient that comes in with COPD, we know that the major area the COPD affects is the lungs. But that patient can also have diabetes. So as I am treating the patient, I can’t just forget about the diabetes. I can’t just do a focus assessment on the lungs. Because I have to treat the whole body. But what we are talking about here is being able to pick up what is system specific assessment is and looking for risk factors for that assessment. You need to do an initial head to toe assessment and then be able to focus on the patient’s primary problem. So when we are looking at a risk assessment, the nurse must be able to clarify what’s going on with her patient. To be able to watch for specific complications in specific areas of the body. So some of the examples again. These are just examples there are lots and lots of patients out there with lots of different examples that you could plug in here. But these examples are just kind of give you an idea on how you should be thinking. We know patients with diabetes have a probability of poor wound healing.

06:29 So again I have my patient with diabetes. They come and they have surgery. I may have nothing to do with their diabetes but as a nurse I know the diabetics have a poor wound healing. So I am really watching my wounds on those patient. What about risks of hyperglycemia in a patient that receiving steroids? May be they are getting steroids because they have COPD or they have asthma and they are on long term steroids. I know that long term steroids can cause hyperglycemia. So again am I watching for that in my patient? Am I focused on watching blood sugars? What about respiratory distress in a patient with asthma? Just because they are on their inhalers, just because they are taking their medicines and they come into the hospital with maybe appendectomy. I don’t want to get so focused on that appendectomy that I forget that they are at risk for respiratory failure.

07:24 What about risk of pulmonary emboli in your patient with a fractured bone? Again remember any patient that has a fractured bone, it can happened immediately and it can happen days afterwards. So again being able to understand that it’s not just the bone but I also need to focus on lungs and watching for those complications. Risk of diminished peripheral circulation in a patient with afib. Remember with afib, the atrium aren't beating the way they should and so what happens is that the blood kind of just sits in the atrium. So how would I catch that if that’s happening in my patient, that’s not on telemetry? You start looking at peripheral pulses and when you can’t feel a radial or popliteal pulse, you will know that something is going on in the central body. Again if I just get focused on just the afib and I am watching a monitor I can miss out on the fact that they are not perfusing.

08:26 So you want to watch for that risk. How about the risk of over hydration in your patient with congestive heart failure that also has anemia and needs a blood transfusion? Again all your patients are getting blood transfusion. You want to make sure that you are listening to the lungs and making sure that we are not over hydrating them and pushing them into a congestive heart failure or an exacerbation of congestive heart failure. How about the risk of dehydration with your patient with hyperemesis? Lot of times women that are pregnant will have a lot of vomiting. Some women have more than others. Some women have other processes going on that cause them to dehydrate a lot faster. So again it’s not so much you know we are watching them and their vomiting. But we are watching for dehydration, we are watching their kidneys, and their perfusion to make sure that we're focused on that part of assessment as well. And then risk of falls in our patients with narcotics. That can be any patient. I think sometimes we get focused on our older patients and that we do need to focus on them. But any patient that were getting narcotics too, any patient’s blood pressure medicines too, we know that there is a risk of falls.

09:35 And so being able to watch for that and assess for that and to keep our patient safe, knowing what kind of side effects happen with those kind of medications. Then responding to changes.

09:50 As you look at lawsuits and negligent cases that are brought against nurses. Many of them are brought because of failure to act, failure to catch a complication happening, failure to catch the trending as it is going on and not seeing other results until after the patient crashes. So you need to make sure that you understand about trending. About looking at lab results and even though the lab results maybe within the normal parameter is it leading more towards to too high or too low and being able to monitor that before gets out of luck.

10:27 Watching for patients vital signs and catching a dropping blood pressure or an increasing heart rate before it gets to the point where the patient starts to code. So again failure to act and failure to act in a timely manner. So how do I know what is going on? Is I have to understand my patient and I have to do good assessments. I have to be able to look at labs and understand are they getting better? Are they getting worse? Are they really staying in a normal range? Trending is a big part of nursing. And again you have to look at labs, you have to look at vital signs, but you also have to look at your patient. And doing thorough assessment and then focusing on potential complications. Again is there a complication with the lungs? Could there be a complication with the blood clot? And am I focusing on that or am I just focusing on what’s happening with the patient at the time? So again as nurses we understand that we are looking at the whole body. It doesn’t necessarily mean I am doing a head to toe assessment. It means that I understand a disease processes and what kind of risk potentials that there are. So make sure you are getting a PRN medicine.

11:36 Make sure that you are following up. Make sure that the medicines that you are giving are doing their intended therapeutic effect. Don’t just assume that when you give somebody a medication, that it is going to go by what the book says. Are you reassessing? Are you looking for potential risk factors? And are you catching potential risk factors and eliminating them before they happen? Make sure that you are looking at your whole patient. Make sure that you understand their disease processes, make sure you understand diagnostic tests, and medications. So that you can preemptively watch for these complications before they happen.

12:18 So get to studying your NCLEX review, take a lot of questions and make sure that you are able to answer. And again as you are answering those questions, make sure you understand what the question is asking you. So that you can make the right choice. Good Luck.