Documentation
The part in SBAR that consists of objective observations and measurements made by the nurse during the shift, with an emphasis on any changes
This is sometimes called the 6th Vital Sign
What is Pain?
Palpate here to assess the sinuses
What is above the eyebrows for frontal and below the cheeks for maxillary?
Used to assess visual acuity
What is the Snellen chart?
These abnormal cues are assessed for in a skin inspection
What is pallor, cyanosis, erythema, and jaundice?
The document name where nurses enter their charting.
What are the Nurse's Progress Notes?
The pulse that needs to be palpated prior to obtaining a blood pressure
What is the brachial pulse?
These lymph nodes are palpated along the angle of mandible
What are the jugulodigastric lymph nodes?
What is assessed for in the external auditory canal?
Hair is inspected for these
What are hair color, texture, and distribution?
Where the date/time, description of bowel movement, and patient response is recorded
What is the Bowel Care Documentation?
The four ways in which a temperature can be obtained
What are Oral, Tympanic, Axilla, and Rectal?
How a patient is assessed for JVD
You would inspect this for patency during a nose assessment
What is a nostril?
You assess for dehydration by checking this
What is skin turgor?
The identification and documentation of physical, emotional, and educational needs of the patient. Also, where you prioritize care and formulate a care plan.
What is the Needs Assessment and Care Plan
What is 30 seconds and multiply by 2 if respirations are regular and a full 60 seconds if respirations are irregular?
Asking the patient to smile, frown, close eyes tightly, and to puff their cheeks assesses this
What is motor function of the face (or CN VII)
Inspection of the tongue includes these
What are inspecting symmetry, movement, coating or lesions?
Clubbing of the nails is often linked to this
What is hypoxia?
How a nursing student at SIIT signs their documentation
What is Nursing Student, SIIT?
Normal Values for Vital Signs
What are:
T 36.5-37.5
RR 12-20/min
HR 60-100 BPM
BP 120/80
O2 Sat 95-100%
The ranges of motion assessed for in the neck
Flexion (Chin to chest)
Extension (looking up)
Lateral bend (ear to shoulder)
Rotate (looking left and right)
PERRLA stands for this
What is pupils equal, round, reactive to light and accomodation?
This scale is used to measure the patient's risk for developing pressure ulcers
What is the Bradan Scale?