Focused Assessment of a Patient with Abdominal Pain
Central Nervous System.
- Assess pain
P – provocative/palliative O – onset R – relieving factors
Q – quality L - location T – time factor
R- radiation D - duration
S – severity C - characteristics
T- timing A – aggravating factors
- Level of consciousness- confusion, restlessness.
- Temperature
- PERRLA
- Orientation to all three dimensions (person, time and place).
- Activity tolerance level
Respiratory system:
- Respiratory rate, rhythm, depth
Use of accessory muscles
- O2 saturation levels
- Auscultation: lung sounds: equality, clarity, presence or absence of adventitious sounds.
Cardiovascular system:
- Blood pressure and heart rate (apical pulse)
- Skin color and cap refill
- Peripheral Pulses
GI
- Inspection: abdominal distension or bruising
- Light palpation for abdominal pain/tenderness
- Auscultate bowel sounds: active, hypoactive or hyperactive
- Medications taken, time of last pain medication
- Nausea or vomiting
GU
- Last bowel movement
- Output: catheter, emesis (if vomiting), drains.
- Catheter drainage (color, clarity, turbidity, sediments, average hourly output should be above 30ml/hr)
Integument
- Monitor drain sites and drain dressings for signs of infection, displacement, or increased amounts of drainage.
- Assess PICC site for signs of infection at the site which would be evidenced by signs of increased skin temperature, pain on palpation around the site, and swelling at the site.
- Skin color
Psycho-social
- Coping pattern
- Signs of confusion
- Sleep pattern
- Ability to comprehend and understand any teaching that should be done
- Participation in social interactions
- Type and frequency of hallucinations
- Mood and affect
