Vital Signs
Head/Neck
Heart/Lungs/Abdomen
Skin/Musculoskeletal
SBAR
100

Wrist pulse name

Brachial

100

This is used to assess visual acuity

Snellen chart

100

T/F: All patient's receive breast exams

True

100

An accumulation of fluid in the tissues 

Edema

100

Based on data and observation.

Assessment

200

Normal respiratory rate

12-20

200

Acronym used to describe the eyes

PERRLA

200

Adventitious breath sounds

Crackles, Wheezes, Rhonchi, Pleural friction rub, Absent

200
Exaggerated lateral curvature

Scoliosis

200

Refers to the immediate issue or reason for the communication

Situation

300

Expected SpO2 reference range

95 - 100%

300

CN's tested through the gag reflex

CN IX, CN X

300

Expected heart sound in older adults, athletes, and children

S4

300

A decrease in muscle size due to disuse

Atrophy

300

Includes relevant clinical history, diagnoses, and context leading up to the current situation.

Background

400

Elevated BP x3 over several weeks

Hypertension

400

Involves placing a vibrating tunning fork against the mastoid bone

Rinne test

400

Located at the L midclavicular line at the 5th ICS

Apical pulse, or point of maximal impulse

400

Acronym used to detect possible skin cancer

ABCDE

400

What the nurse thinks should be done or is requesting

Recommendation

500

Contraindications for rectal temperatures

diarrhea, bleeding precautions, rectal disorders

500

Used to obtain a baseline level of consciousness

Glasgow Coma Scale

500

Correct order for an abdominal assessment

Inspection, Auscultation, Percussion, Palpatation

500

Abnormal skin colors

Pallor, Cyanosis, Jaundice, Erythema

500

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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