Vital Signs
Wrist pulse name
Brachial
This is used to assess visual acuity
Snellen chart
T/F: All patient's receive breast exams
True
An accumulation of fluid in the tissues
Edema
Based on data and observation.
Assessment
Normal respiratory rate
12-20
Acronym used to describe the eyes
PERRLA
Adventitious breath sounds
Crackles, Wheezes, Rhonchi, Pleural friction rub, Absent
Scoliosis
Refers to the immediate issue or reason for the communication
Situation
Expected SpO2 reference range
95 - 100%
CN's tested through the gag reflex
CN IX, CN X
Expected heart sound in older adults, athletes, and children
S4
A decrease in muscle size due to disuse
Atrophy
Includes relevant clinical history, diagnoses, and context leading up to the current situation.
Background
Elevated BP x3 over several weeks
Hypertension
Involves placing a vibrating tunning fork against the mastoid bone
Rinne test
Located at the L midclavicular line at the 5th ICS
Apical pulse, or point of maximal impulse
Acronym used to detect possible skin cancer
ABCDE
What the nurse thinks should be done or is requesting
Recommendation
Contraindications for rectal temperatures
diarrhea, bleeding precautions, rectal disorders
Used to obtain a baseline level of consciousness
Glasgow Coma Scale
Correct order for an abdominal assessment
Inspection, Auscultation, Percussion, Palpatation
Abnormal skin colors
Pallor, Cyanosis, Jaundice, Erythema
Mr. Lopez is 1 day post-op appendectomy. His most recent BP is 82/50. He is pale, sweaty.
What is your SBAR?
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