1. An alternate method of assessment ASSESSMENT BY BODY SYSTEM

2. a.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 I. INTRODUCTION TO THE CLIENT

3. a.Temperature b.Pulse c.Respirations d.Blood Pressure e.Pain Assessment f.Weight/Height g.O ₂ Saturation II. VITAL SIGNS

4. a.Level of Consciousness 1.Stimulus Response b. Pupils (PERRLA)-examination of clients eyes 1.Pupils Equal Round Reactive to Light and Accommodation 2.Means the ability of the eyes to focus on objects that are close up and faraway III. NEUROLOGICAL ASSESSMENT

5. Glasgow Coma Scale ResponseScore Eye OpeningSpontaneous To verbal command To pain No response 43214321 Motor ResponseTo verbal command To painful stimuli- -Localizes pain -Flexes and withdraws -Assumes Flexor posturing -Assumes Extensor posturing No response 654321654321 Verbal Response (arouse patient with painful stimuli if necessary) Oriented and Converses Disoriented and Converses Uses Inappropriate Words Makes Incomprehensible Sounds No response 5432154321

6. a.Pulses- Apical, Radial, Pedal Quality & Rate Bilaterally b.Capillary Refill c.Neck Veins d.Edema-check feet, hands, scrotum e.Heart Sounds-lub/dub, rhythm, murmurs f.Sighs and Symptoms of Shock 1.Increased heart rate 2.Decreased blood pressure g. Cool, clammy skin IV. CARDIAC ASSESSMENT

7.  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 B. CAPILLARY REFILL

8.  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 C. NECK VEINS

9. Distended VeinsFlattened Veins NECK VEINS

10. a.Facial Symmetry 1.Check teeth, raise eyebrows b. Hand grips c. Movements & Strength of Extremities 1.Patients extends arms, check reflexes V. MOTOR FUNCTIONING

11. a.Inspection of skin color, barrel chest of emphysema b.Auscultation 1.Lung sounds-wales/crackles, wheezes c. Sputum-color consistency d. Cough-productive, non productive e. Oxygen administration and response VI. RESPIRATORY ASSESSMENT

13. a.Inspection- flat, round, distended b.Auscultation 1.Bowel sounds; 4 quadrants - hypoactive, active, hyperactive, absent 2. Listen for abdominal aorta bruit c.Palpation- pain?, deep to determine liver margins d.Percussion- air, fluid? e.Nausea, Vomiting, Dyspepsia, Anorexia f.Nutrition-intake, pain when eating, appetite g.Lab Values-protein, prealbumin(blood test) VII. GASTROINTESTINAL & ABDOMINAL ASSESSMENT

15. a.Intake and Output b.Peripheral Edema c.Diaphoresis (excessive sweating) d.I.V. Site e.Lab Values- electrolytes VIII. FLUIDS & ELECTROLYTES

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

17. a.Muscle Strength 1.Mobile? Immobile X. MUSCULOSKELETAL ASSESSMENT

18. a.Senses b.Diabetic c.Thyroid a.Hearing, vision b.Glucose levels, altered levels of consciousness, Feet/skin c.Monitor heart rate & blood pressure XI. ENDOCRINE/REGULATION

19. a.Decubiti (when in lying down position) b.Nutrition a.redness, lesions, skin to muscle & to bone b.Intake, likes/dislikes, output XII. INTEGUMENTARY SYSTEM

20. a.Affect of illness on role; such as work, family b.Inappropriate independence, dependence? c.Check for depression, suicidal ideation of needed XIII. PSYCHOSOCIAL ASPECTS