2 what body systems will you assess most thoroughly

2. What body system(s) will you assess most thoroughly performing a FOCUSED assessment based on
the primary/priority problem? Identify correlating specific nursing assessments.
(NCLEX: Reduction of Risk Potential/Physiologic Adaptation)
PRIORITY Body
System:
PRIORITY Nursing Assessments:
Respiratory fever (possible) , cough , shortness of breath, chills, muscle pain , new loss of taste or
smell, vomiting or diarrhea and/or sore throat .
Current FOCUSED Nursing Assessment:
GENERAL SURVEY: Appears anxious, body tense
NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4), generalized weakness
HEENT: Head normocephalic with symmetry of all facial features. Lips, tongue, and oral mucosa
pink and moist.
RESPIRATORY: Breath sounds fine dry crackles bilat. with diminished aeration on inspiration and expiration
in all lobes anteriorly, posteriorly, and laterally, non-labored respiratory effort, episodic
non- productive cough
CARDIAC: No edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-
tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-
P-T-M
cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees.
ABDOMEN: Deferred
GU: Deferred
INTEGUMENTARY: Skin hot, dry, intact, normal color for ethnicity. Skin integrity intact, skin turgor elastic,
no tenting present.
3. What assessment data is RELEVANT and must be NOTICED as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data: Clinical Significance:

Cough, bilateral crackles, diminished
aeration, fever
Fever and weakened pulmonary function could indicate infection by COVID-19

4. Interpreting clinical data collected, what problems are possible? Which problem is the PRIORITY? Why?
(NCSBN: Step 2: Analyze cues/Step 3: Prioritize hypotheses/NCLEX: Management of Care)
Problems: Priority Problem: Rationale:
Decreased tissue
perfusion
ineffective airway
clearance
Ineffective Airway
Clearance
PT is demonstrating decreased o2 saturation and bilateral crackles. If airway
is not addressed, PT will likely develop secondary problems like infection or
hypoxia related damage
5. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care?
(NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX: Management of Care)
Nursing PRIORITY: Ineffective Airway Clearance
GOAL of Care: Maintain airway patency, demonstrate improved oxygen exchange
Nursing Interventions: Rationale: Expected
Outcome:
Assist client in airway clearance techniques
Monitor respirations and breath sounds
Observe for signs/symptoms of infection
To improve respiratory function and gas exchange
To monitor for respiratory distress or accumulation of
secretions