GI
When auscultating bowel sounds, the nurse should listen in this quadrant first, as it is where sounds are usually most active.
What is the right lower quadrant?
The nurse asks the patient about the color, odor, frequency, and pain associated with urination when assessing this type of data.
What is subjective data?
During a head-to-toe assessment, the nurse first inspects this part of the body for symmetry, movement, and signs of pain.
What is the head or face?
The nurse palpates the skin to check for this, which may indicate dehydration or fluid imbalance.
What is skin turgor?
The nurse checks this to assess a patient’s ability to recognize objects or people, which may be impaired in neurological conditions.
What is orientation or level of consciousness?
When assessing a patient’s bowel habits, the nurse asks, "When was this?" to gather information about this important factor.
What is the last bowel movement?
The presence of protein in the urine, which may be a sign of kidney disease, is called this.
What is proteinuria?
The nurse checks for this by gently pressing on the patient's skin over the shins or ankles, looking for pitting that indicates fluid retention.
What is edema?
The nurse inspects the nails for this, which may be a sign of anemia or oxygen deficiency.
What is clubbing of the nails?
The nurse assesses the patient’s pupils for this response to light, which helps evaluate brain function.
What is PERRLA
The nurse uses a stethoscope to assess this type of objective data in all four quadrants of the abdomen.
What are bowel sounds?
The nurse documents this term when a patient reports pain or burning during urination, often associated with a urinary tract infection (UTI).
What is dysuria?
During the head-to-toe assessment, the nurse checks the patient’s hands and nails for this condition, which may indicate poor circulation or oxygenation.
What is cyanosis?
The nurse looks for this type of skin change, where the skin turns red, and may indicate early signs of a pressure ulcer.
What is erythema or redness?
During a neurological exam, the nurse tests this by asking the patient to lift their eyebrows, smile, and puff out their cheeks.
What is facial nerve function?
When auscultating the abdomen, the nurse hears a whooshing sound over the aorta, which may indicate turbulent blood flow due to this condition.
What is an abdominal bruit?
The nurse documents this term when a patient’s urine output is less than 400 mL per day, which may indicate dehydration or kidney dysfunction.
What is oliguria?
The nurse inspects this area to check for any changes in the patient's mouth, such as lesions, sores, or inflammation.
What is the oral cavity?
The nurse inspects this part of the body for any signs of bruising, which could indicate trauma or clotting issues.
What is the extremities or limbs?
The nurse observes the patient’s ability to walk in a straight line to check for this type of balance.
What is coordination or gait?
When percussing the abdomen, the nurse expects to hear this sound over areas filled with gas, such as the stomach and intestines.
What is tympany?
The presence of blood in the urine, which may be caused by infection, kidney stones, or trauma, is known as this condition.
What is hematuria?
The nurse checks this part of the body to assess the patient's pulse rate, rhythm, and strength.
What is the wrist or radial pulse?
The nurse checks this part of the body for redness or irritation, especially after a patient has been lying in bed for a long period.
What are pressure points or bony prominences?
The nurse checks this reflex by tapping the bottom of an infants foot and observing the toes' response, which should normally flex.
What is the Babinski reflex?