Focused Assessment, Oxygen Devices, & Medication – NURS 1871 Nursing Study Guide (CSCC)

** Focused Assessment, Oxygen Devices, & Medication NURS 1871 **
Body Systems That Could Be Evaluated (System-Specific Focused Assessment)

●​ Cardiovascular: Heart sounds, pulses, BP, edema, perfusion "APT M 2245"​

●​ Respiratory: Lung sounds, respiratory rate, oxygenation, effort​

●​ Gastrointestinal: Bowel sounds, palpation, nausea/vomiting, digestion​

●​ Genitourinary: Urination patterns, bladder distention, genital exam​

●​ Neurological: LOC, pupil response, motor/sensory function​

●​ Musculoskeletal: Range of motion, strength, gait, joint pain​

●​ Integumentary: Skin integrity, wounds, color, temperature

Anatomical Body Regions That Could Be Assessed (Region-Specific Focused Assessment)

●​ Head and Neck: Eyes, ears, nose, throat, lymph nodes, thyroid​

●​ Chest and Lungs: Thorax, respiratory effort, breath sounds​

●​ Heart and Peripheral Vascular: Chest, extremities, pulses, cap refill​

●​ Abdomen: RUQ, LUQ, RLQ, LLQ – palpation, bowel sounds​

●​ Back/Spine: Curvature, tenderness, ROM​

●​ Extremities: Arms, legs, joints, circulation, movement​

●​ Pelvis/Genital Region: Reproductive organs, urinary system​

●​ Skin/Wound Area: Lesions, rashes, surgical sites​

●​ Perineal Area: Especially in incontinence or catheter care​

●​ Cranial Nerves (Face & Sensory Regions): Neurological assessments

Common Specific Concerns or Symptoms (Problem-Focused Assessment)

●​ Pain (acute, chronic, localized, referred) “PQRST”
●​ Fever
●​ Nausea/Vomiting
●​ Cough or Shortness of Breath
●​ Fatigue or Weakness
●​ Edema or Swelling
●​ Bleeding or Bruising
●​ Headache or Dizziness
●​ Confusion or Altered Mental Status
●​ Incontinence or Urinary Retention
●​ Diarrhea or Constipation
●​ Rash or Skin Changes
●​ Weight Gain or Loss

, ●​ Vision or Hearing Changes
●​ Falls or Balance Issues
●​ Anxiety or Depression Symptoms

Before Treatment or Procedure Assessments (Procedure-Focused Assessment)

●​ Preoperative Assessment: Allergies, NPO status, labs, vitals, surgical site​

●​ Pre-catheterization: Bladder fullness, perineal hygiene, allergies (latex, Betadine)​

●​ Pre-IV Insertion: Skin condition, veins, previous IV sites​

●​ Pre-blood transfusion: Blood type match, baseline vitals, consent​

●​ Pre-vaccination: Allergy history, current symptoms (fever, illness)​

●​ Before Medication Administration: Allergies, vitals, lab values, last dose​

●​ Pre-therapy Assessments: (e.g., wound care, physical therapy) range of motion, skin status​

●​ Before Diagnostic Tests (e.g., EKG, X-ray): Relevant history, positioning, prep instructions​

●​ Before Sedation or Anesthesia: NPO status, airway assessment, consent​

●​ Before Dialysis: Weight, vitals, fistula site, lab work​

●​ Before Blood Glucose Checks: Last meal, symptoms of hypo/hyperglycemia


Oxygen-Delivery Systems

●​ Incentive spirometer (IS) – Nurse teach back
○​ Patient to blow into
○​ 10 times per hour
○​ Hold as long as you can breathe out

●​ Nasal cannula: 1–6 L/min

●​ Simple face mask: 6–12 L/min

●​ Partial Rebreather Mask: 6–10 L/min (no valve)
○​ (Bag should always remain partially inflated – person is able to “rebreathe” some of their
exhaled air)​

●​ Non Rebreather Mask (EMERGENCY): 10-15 L/min (has one way valve)
○​ (Person can suck oxygen out of the bag, but can never breathe back into the bag)
■​ COPD (depends on the patient if they will get one)
■​ Asthma
■​ Respiratory distress

●​ Ambu bag (bag-valve-mask or BVM): handheld device used to provide positive pressure ventilation to
patients who are not breathing or breathing inadequately (manually pump bag if patient is dead or in
respiratory distress