Abdominal
4 Quadrants
What is LOC?
Person, Place, Time, and Situation.
What is the pulse rate range for an adult?
60-100 bpm
What is the range for breath sounds per minute for adults?
12-20 breaths per minute
What do you look for during a skin assessment? (4 things)
Temperature, texture, wounds, correct skin color.
In what order should you do an abdominal assessment?
Inspection, Auscultation, Palpation
What is PERRLA?
Pupils equal, round, reactive to light with accommodation.
What are the 5 locations for heart sounds?
Aortic, Pulmonic, Erb's Point, Tricuspid, and Mitral
How many spots on the anterior chest and posterior chest would you listen for lung sounds?
6 fields, 8 fields
What does skin turgor indicate?
How long would you listen for bowel sounds if you do not hear anything?
5 minutes x 2 nurses.
What could a facial droop indicate?
Which heart sound should you listen for a full minute?
Apical
Name 2 adventitios lung sounds
wheeze
crackles
roncki
rales
friction rub
Skin tenting suggests what?
dehydration
Why do you listen to abdomen before you palpate it?
Palpating the abdomen may cause bowel sounds to occur that would not have normally been there.
How do you check the strength of a client's upper and lower extremities?
Have client squeeze hands bilateral, push and pull feet against your hands.
Where is the radial pulse found?
radial (thumb) side of wrist
When observing a patient, what signs are is the nurse looking for to assess for respiratory distress?
SOB, DOE, accessory muscle use, cyanosis, cough
What is edema?
swelling
What additional subjective data would the nurse collect when performing an abdominal assessment?
Nausea/Vomiting/Diarrhea, Last BM?
What is a normal pupil size?
2-3mm
How do you assess capillary refill and what is normal?
Press the fingertips and release. Refill should occur 2-3 secs
How do you assess a cough?
Productive or non productive, sputum characteristics - color, consistency, odor
When performing a skin assessment, what is the nurse inspecting for?
Skin color for uniformity, skin lesions, scars, incisions, wounds