Heart
Auscultate for 5 full minutes
What is absent bowel sound assessment?
After pressure has been applied to cause blanching, the capillary bed should regain its color after ____. This is called _____.
What is... 2 seconds; Normal Cap Refill
A CRT longer than 2 seconds is indicative of poor perfusion due to peripheral vasocontriction
What are normal heart tones?
S1-S2
What are things to document on a respiratory assessment?
Respiratory rate, respiratory findings, any unexpected outcomes
What is the number of areas auscultated during an abdominal assessment?
4 quadrants
This pulse is palpated behind the knee
What is... Popliteal
Point of Maximum Impulse
What is apical/mitral?
Locate, identify, and auscultate anterior breath sounds in systematic and symmetrical manner, that covers all lung fields
What is a respiratory assessment?
A nurse knows that when a patient experiences pain while walking or exercising, this is called___?
What is... Intermittent Claudication
What is the location of the heart?
Left side of chest- apical is 5th intercostal space midclavicular space
Wheezing, course crackles, rales, rhonchi
What are adventitious/abnormal lung sounds?
What are things to document about abdominal assessment?
Appearance of abdomen, quality of bowel sounds, presence of distention, abdominal circumference, and presence and location of tenderness
In a patient with DVT in the femoral vein, the nurse can expect the extremities to feel _____
What is Cool and clammy?
15-item neurological examination used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss.
What is the NIH stroke scale?
Place hand on patients back with thumbs together and ask patient to take a deep breath
What is assessment of posterior chest symmetry
What is possible constipation/bowel obstruction assessment findings?
Firm, distended abdomen
Irregularly shaped, usually painless ulcers on lower legs and ankles
What is... venous insufficiency