Abdomen
What is the first step in assessment of the abdomen?
What is INSPECTION
Where do we assess pulse rate and for how long do we count the bpm?
Apical Pulse
60 seconds
What is the term for difficulty breathing in the supine position
orthopnea
The most distal pulse site is?
Dorsalis Pedis
What does AAOX4 mean?
Awake, Alert, Oriented, x4
Why must the abdomen be assessed in a certain, specific sequence?
To avoid causing false hyperactive bowels sounds
How many cardiac auscultation sites are there to assess each time?
What is 5?
Aortic- pulmonic- ERB's point-tricuspid- mitral(APICAL PULSE)
What is adventitious breath sounds and give 3 examples of.
Abnormal lung sounds
Crackles/rales
Rhonci
Wheezes
Stridor
Diminished
A bounding pulse is associated with what?
What is Hypertension or excess fluid volume
You have a patient with an injured hip. When the patient stands, the pain goes to his lower back and down his leg. What type of pain is this?
What is radiating pain?
Name 3 subjective data that can be gathered during abdomen assessment.
N/V
LBM
Anorexia/Appetite
Flatulence
Indigestion
Pain/Cramps
Give me the physical landmarks of the apical pulse site(PMI)
3-4 inches left of the sternum
mid-clavicular
5th intercostal space
Are you spitting anything up with it?
Describe the secretion/output/phlegm..
Name the 7 peripheral pulse sites
Carotid
Radial
Brachial
Femoral
Popliteal
Dorsalis Pedis
Posterior Tibialis
If a patient is asleep and does not respond to verbal stimuli, what is the next level of stimuli and give me an example of it. The third level of stimuli..and give me an example.
Tactile stimuli (touch) shoulder, gently shake
Pain(pressure on nailbed/sternum)
Describe proper abdomen auscultation assessment
Auscultate quad x4; x1mn each
5-30 clicks
<5 hypo
>30 hyper
What are the 3 assessment pieces of apical heart rate?
rate, rhythm, strength
Give me 4 components of a focused respiratory assessment
Respirations
Use of accessory muscles
The color/temp of skin and nail beds
Auscultation of lungs
SPO2
What are the different assessments for adequate circulation to the extremities? Name 3 at least
What is pulse strength and equality, color, skin temperature, sensation,
Name at least 4 Physiological symptoms of acute pain
PHYSIOLOGICAL: Recent onset; Fight or Flight response (HR increase, RR increase, Systolic BP increases, Pupils dilate); Diaphoresis, BP may drop if not handled, syncope
What is the term used to describe bowel sounds that are audible without a stethoscope?
How would you describe the difference in the two heart sounds? (LUBB - DUBB)
The first heart sound (LUBB), is the louder of the two heart sounds, lower frequency; closure of mitral and tricuspid valves
The second heart sound (DUBB) follows a short pause. This sound is shorter and higher pitched that S1; closure of the aortic and pulmonary valves
You have a patient with pneumonia and a non-productive cough. Consolidation is suspected when what is assessed during auscultation of the lungs.
Absent breath sounds OR incredibly diminished breath sounds.
+2 pitting edema is how deep of an indention?
4 mm
What does PERRLA stand for and how do we assess for it?
Pupils Equal Round Reactive to Light and Accommodation
Penlight test, consensual reflex with penlight shining into each eye.