In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of system specific assessments in order to:

  • Assess the client for abnormal peripheral pulses after a procedure or treatment
  • Assess the client for abnormal neurological status (e.g., level of consciousness, muscle strength, and mobility)
  • Assess the client for peripheral edema
  • Assess the client for signs of hypoglycemia or hyperglycemia
  • Identify factors that result in delayed wound healing
  • Recognize trends and changes in client condition and intervene as needed
  • Perform a risk assessment (e.g., sensory impairment, potential for falls, level of mobility, skin integrity)
  • Perform focused assessment

Assessing the Client for Abnormal Peripheral Pulses after a Procedure or Treatment

Many procedures and treatments place the client at risk for an alteration in terms of their peripheral pulses. These peripheral pulses include the radial pulse, the femoral pulse, the brachial pulse, the popliteal pulse, the dorsalis pedis pulse of the foot and the posterior tibial pulse near the ankle. These pulses are assessed in terms of their rate, volume, and regularity bilaterally. A Doppler can be used when the peripheral pulses are difficult to palpate.

The strength, volume and fullness of the peripheral pulses are categorized and documented as follows:

  • 0: Absent pulses
  • 1: Weak pulse
  • 2: Normal pulse
  • 3: Increased volume
  • 4: A bounding pulse

Assessing the Client for An Abnormal Neurological Status

Nurses assess the client's neurological status in terms of the client's level of consciousness, muscle strength, mobility and the functioning of the cranial nerves and neurological reflexes.

The client's level of consciousness is assessed as oriented to time, person and place, also referred to as oriented x 3, fully awake but not fully oriented, arousable with some stimuli, and not responsive. They can also be assessed as alert, confused, lethargic, obtunded, stuporous, or comatose as well as having a persistent vegetative state, locked in syndrome or brain death, as discussed previously in the section entitled "Assessing the Client's Appearance, Mood and Psychomotor Behavior and Identifying and Responding to Inappropriate and Abnormal Behavior".

Muscular strength, like peripheral pulses, are assessed bilaterally for equality and the strength of the muscles are assessed and documented from 0 to 5 as shown below.

Muscular strength is assessed with manual muscle testing and using a dynamometer. Muscular strength is also assessed in terms of bilateral equality and other characteristics.

The strength of muscles is classified and documented as follows:

  • 0: The lack of visible muscle contraction
  • 1: Visible muscle contraction with the absence of any movement
  • 2: Muscular contraction coupled with an inability to move against the force of gravity
  • 3: Full muscle contraction and movement without the ability to move against resistance
  • 4: Full muscular contraction and movement coupled with some limitation with resistance
  • 5: Full muscular contraction and movement against high levels of resistance

or

  • 0: Muscle contraction is not visible
  • 1: The presence of a contraction and the absence of movement
  • 2: Muscular contraction and the inability to move the bodily part against the force of gravity
  • 3: Full contraction and movement
  • 4: Full contraction and movement but with some limitation when resistance is applied
  • 5: Full contraction against high levels of resistance and full movement

Mobility

The needs of the client in terms of their mobility, movement, activity and exercise are impacted by a number of different factors including neurological function, joint mobility, bodily alignment, coordination, balance and gait. Many of these factors are neurological in nature. For example, joint mobility can be impaired as the result of paralysis secondary to a cerebrovascular accident, bodily alignment can be negatively impacted when the client has a lack of balance as the result of altered visual ability, impaired neurological stretch receptors, and the nerves within labyrinth of the ear; and impaired coordination can occur as the result of cerebral cortex, basal ganglia and cerebellum abnormalities.

The cranial nerves are assessed in terms of their sensory and motor functioning. As previously discussed in the section entitled "The Assessment of the Neurological System", the twelve unique cranial nerves include:

  1. Olfactory cranial nerve
  2. Optic cranial nerve
  3. Oculomotor cranial nerve
  4. Trochlear cranial nerve
  5. Trigeminal cranial nerve
  6. Abducens cranial nerve
  7. Facial cranial nerve
  8. Acoustic cranial nerve
  9. Glossopharyngeal
  10. Vagus cranial nerve
  11. Spinal accessory cranial nerve
  12. Hypoglossal cranial nerve

Reflexes, including the primitive reflexes are assessed as previously detailed and described in the section entitled "The Assessment of the Neurological System". For example the primitive Moro or startle reflex, the primitive step reflex, the reflexes of the pupils are assessed for dilation and pupil accommodation, and the plantar reflex is assessed by stroking the soles of the client's foot.

Assessing the Client for Peripheral Edema

Peripheral edema, sometimes referred to as dependent edema, can be present with a number of physiological disorders such as fluid overload, infection, poor venous circulation, and some cardiac disorders. Edema results when fluids collect and accumulate in the interstitial and/or intravascular spaces.

Nurses assess edema in terms of its location and severity. Pitting edema is classified as 1+ to 4+ edema with 1+ pitting edema as edema that remains indented 1 cm or less and 5+ as pitting edema that remains indented 5 cm; and it can also be described and documented as 1+ to 4+ with 1+ pitting edema as edema that is difficult to detect and 4+as pitting edema that remains indented > 75 cm.

Assessing the Client for Signs of Hypoglycemia or Hyperglycemia

The most commonly occurring signs and symptoms of diabetes mellitus result from hyperglycemia. Nurses assess clients for these signs of hyperglycemia:

  • High blood glucose levels
  • Blurred vision
  • Nausea and vomiting
  • Polyuria
  • Urinary frequency
  • Polydipsia
  • Dehydration
  • Fatigue
  • Alterations in terms of mental status like confusion
  • Weakness
  • Orthostatic hypotension

Hypoglycemia also has a number of signs and symptoms including a headache, anxiety, slurred speech, dizziness, lightheadedness, a headache, diaphoresis, irritability and hunger which are the early signs of hypoglycemia. The later signs of hypoglycemia include:

  • Low blood glucose levels
  • Alterations in terms of consciousness including confusion and the state of unconsciousness
  • Lethargy
  • Convulsions
  • Seizures
  • Unconsciousness
  • Clumsiness and a lack of coordination
  • Muscular weakness
  • Agitation
  • Coma
  • Death

The signs and symptoms of diabetic ketoacidosis are:

  • Ketones in the urine
  • A very high blood glucose level
  • Breath with a fruity odor
  • Fatigue
  • Respiratory shortness of breath
  • Nausea and vomiting
  • Abdominal pain
  • Confusion
  • Excessive thirstiness
  • Frequent urination

Initial signs and symptoms of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) include:

  • Excessive thirst
  • A fever
  • Muscular weakness
  • Convulsions
  • Seizures
  • Increased urination
  • Lethargy
  • Nausea
  • Confusion
  • Coma

Identifying Factors That Result in Delayed Wound Healing

Some of the factors that can result in delayed and other wise impaired wound healing include:

  • Age: Advancing age is a risk factor associated with delayed and impaired wound healing because of some of the normal and expected changes related to the aging process and also because aging clients are more likely to be affected with chronic and long term diseases and disorders, such as diabetes, that can delay wound healing.Some of the normal and expected changes related to the aging process that impact on poor wound healing include slower cell renewal, a decreased immune system which impedes the production of monocytes and antibodies that are necessary for wound healing, vascular changes that interfere with the blood flow to and the oxygenation of the wound area, and less elastic collagen and scar tissue which could make the wound more fragile and more easily disrupted.
  • Nutritional Status: Obesity and poor nutrition in terms of the inadequate intake of protein, lipids, carbohydrates, vitamins like vitamins C and A, copper, zinc, iron and minerals can lead to delayed and impaired wound healing.
  • Lifestyle Choices: Lifestyle choices including poor dietary habits and cigarette smoking which reduces the oxygenation of the healing tissue can impede optimal wound healing.
  • Some Medications: Some medications that can delay and disrupt optimal wound healing include antineoplastic medications, steroids, and other anti-inflammatory medications including aspirin.
  • Some Diseases and Disorders: Diabetes, cardiovascular, circulatory and respiratory disorders are examples of diseases and disorders that can impair wound healing.

The different types of wound healing including primary secondary and tertiary healing, the phases of the wound healing process and other aspects of wound healing were previously discussed in the section entitled "Performing a Skin Assessment and Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown".

Recognizing Trends and Changes in Client Condition and Intervening as Needed

Nurses recognize and monitor trends and changes in the client's condition and, after this assessment, they intervene as needed.

Many of these interventions include notifying the doctor of these significant changes, performing further assessments to refine the nurse's decision making, and performing independent nursing functions that are within the nurse's scope of practice as indicated by these client changes and trends.

Performing Risk Assessments

Nursing assessments and nursing diagnoses address not only actual health problems but also the risk factors that place a client in a position that makes them more prone to a disease or disorder than other clients. For example, the client with diabetes is at risk for a number of different short term and long term complications such as hyperglycemia, hypoglycemia and peripheral neuropathy; the client with poor nutrition as a risk factor is more apt to be adversely affected with poor wound healing and cardiac disease; clients with a sensory impairment are at greater risk for medical errors and accidents; clients with a neurological deficit and muscular weakness have a greater potential for falls when compared to other clients; and, immobile clients are at greater risk for all the complications of and the hazards related to immobility.

Nurses perform these risk assessments to prevent the occurrence of a disorder or illness. For example, clients who are assessed as a high risk for skin breakdown or falls must have special preventive measures put into place to avoid an actual health problem such as skin breakdown and falls, respectively.

Performing a Focused Assessment

Although registered nurses perform a complete health history and a comprehensive head to toe assessment, there are many occasions when a focused assessment is done. For example, clients at risk for or affected with a chronic or acute respiratory disorder will be assessed by the nurse in terms of their respiratory status including the assessment of the client's breath sounds and arterial blood gases, and clients with a cardiac disorder will be assessed with a focused assessment of their ECG and heart sounds.

RELATED CONTENT:

SEE - Reduction of Risk Potential Practice Test Questions