start w P
Located at the 2nd intercostal space left sternal border
Pulmonic Valve
Position for assessing Jugular Venous Distention (JVD)
30-45 degrees
Muscle Strength
5 - Active movement against gravity and examiner’s full resistance
With feet together and eyes closed, patient sways, falls, or spreads feet
+ Romberg Sign
Frequency of “Normoactive bowel sounds”
Every 5-15 Seconds
Pinpoint bruising
Petechiae
Popping or crackling sensation when palpating the chest or a joint
Crepitus
Chest diameter
1:2 Anteroposterior: Transverse/Lateral Diameter; no barrel chest
Loud, high pitched normal breath sounds heard over the trachea
Bronchial
Location of Apical Pulse
5 th intercostal space, midclavicular line
Inflamed lung surfaces rub together and cause grating sound
Pleural Friction Rub
Describe how to assess for a CVA
BEFAST Loss of balance? Loss of vision in one or both eyes? Face uneven? Arm weak or numb? Speech slurred? Time to call for assistance immediately.
Abdominal assessment
Soft, non-distended, normoactive bowel sounds
Breath sound heard only on inspiration; associated with mechanical obstruction at the level of the trachea/upper airway.
Stridor
Increased pulse strength/bounding
3+
Pulse that is located behind the medial malleolus
Posterior Tibial
Order of abdominal assessment
Inspection - I
Auscultation - Am
Percussion - Perfect
Palpation - Pal
Pupil Assessment
PERRLAPupils equal 3-5 mmRound, Reactive (brisk), constrict to light, dilate in dark, constrict looking near, dilate looking far
Moderate pitting edema, 4 mm depression, disappears in 10-15 seconds
2+
The 6 Ps of a neurovascular assessment
Pain, Pulse, Pallor, Paresthesia, Paralysis, Poikilothermia
Demonstrate how to assess Cranial Nerve V
Trigeminal - Demonstrate on patient’s hand first; close eyes; stroke and poke on face; clench jaw
T-P-R-BP-O2 Sat
T – 97-99 degrees F
P – 60-100 bpm
R – 12-20 breaths/min
BP – Less than 120/80
O2 Sat – 94-100%
Name this chart and interpret what 20/50 vision means
20/50 vision on the Snellen Eye Chart means that the client stands 20 feet away from the chart and can read the 20/50 line (line 4) clearly but cannot read anything smaller. This means that someone with 20/20 vision (aka "normal" vision) could stand 50 feet away from the chart and read the 20/50 (line 4) clearly
Describe the purpose of and the low risk score (better prognosis) for the Glasgow Coma Scale, Morse Fall Scale, and Braden Scale
Glasgow Coma Score – 15 (high); Morse Fall Scale – 0 (low); Braden Score – 23 (high)